Correct!
4. 1 and 3
In addition to clinical improvement, reducing the IgE level by 35% is considered a satisfactory response. Attempts to normalize the IgE level are not indicated. Close follow up is important in the management of ABPA both to ensure the disease goes into remission and to limit the use of steroids to only as necessary. Monitoring the IgE level is an important aspect of chronic disease management as a doubling in the baseline of the IgE level can signify an impending exacerbation. The astute clinician can often prevent complications like respiratory failure and hospitalization by adding back or increasing the steroids based on the IgE level. If the patient cannot be tapered off steroids then consideration to alternative day dosing of steroids can be considered as a method to achieve the lowest possible necessary dose.
ABPA is staged in five stages with stage I representing acute disease, stage II remission, stage III Exacerbation, stage IV glucocorticoid-dependent disease and stage V end-stage or fibrotic disease. It is important to monitor patient’s closely after the diagnosis of ABPA. Care should be directed at attempts to get the disease into remission and prevent long term complications including respiratory failure, the development or worsening of bronchiectasis and pulmonary fibrosis.
Case Continued:
Following removal of the thick mucus plugs the patient was successfully extubated without further complication. Serum IgE level came back at 6100 ɥg/ml. She was started on high dose steroids and voriconazole and has had a good clinical response.
References