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P162 The allergist, chronic cough and upper airway cough syndrome
S70
Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 117 (2016) S22eS124
Odds of a diagnosis of OSA by asthma control and ICS use
P162 THE ALLERGIST, CHRONIC COUGH AND UPPER AIRWAY COUGH SYNDROME T. Nsouli*1, N. Diliberto2, A. Nsouli1, C. Davis1, K. Cofsky1, J. Bellanti1, 1. Washington, DC; 2. washington, DC. Introduction: Chronic cough (CC) is the most frequent symptom for which patients seek medical care and among the most perplexing and frustrating disease provoking diagnostic challenges for the clinician. One of the frequent causes of CC is postnasal drip. The Practice Guidelines, however, recommend replacing the term postnasal drip syndrome with upper airway cough syndrome (UACS) (Pratter MR. Chest. 2006;129:63S). This study explores the etiologies of CC and treatment options for patients referred to our allergy-immunology clinic. Method: Using The Expert Panel Report on Cough (Lewis SZ, et al. Chest 2014; 146: 1395), study patients were randomized on the basis of clinical history, physical examination, allergy skin prick tests, spirometry, FeNO, appropriate imaging, and others. Results: A total of 137 patients with CC (age 9-68 yr, mean age 32 yr, 72 females, 65 males), with median cough duration of 1.2 years were entered into the study. The etiologic classification of CC in the study population was as follows: 33.57% cough variant asthma, 24.08% UACS, 21.60% LPR/GERD, 15.32% allergic asthma, 8.75% habit cough, 8.02% post-infectious, 6.56% chronic bronchitis, 5.83% cough associated with ACE-I, 4.37% bronchiectasis, 2.91% eosinophilic bronchitis and 6.56% unknown origin. Each condition existed alone or in combination. A carefully crafted treatment resolved CC in 92% of patients. Conclusion: This study further supports the role of UACS in CC and, with allergic asthma and LPR/GERD, forms the most frequent contributors to cough. It also underscores the overlapping etiologic features of the condition and highlights the role of the allergistimmunologist in unraveling the diagnostic challenge.
P163 OMALIZUMAB TREATMENT IN TEEN PATIENT WITH SEVERE ASTHMA AND EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS: CASE REPORT D. Garcia Fajardo*1, H. Perez2, B. Del Rio Navarro3, O. Saucedo Ramirez3, J. Del Rio-Chivardi3, E. Rodriguez3, 1. Rioverde, SL, Mexico; 2. Menda, YU, Mexico; 3. Mexico City, DF, Mexico.
Introduction: The formely Churg-Strauss syndrome is extremely rare in children, ANCAS are positive only in 25% of pediatric patients, most commonly affects the lungs. We present the case of a teenager diagnosed with severe asthma due to this syndrome with poor response to treatment and subsequent clinical improvement after omalizumab treatment. Case: Female 13 years old diagnosed with asthma with poor control of symptoms, classified as severe asthma. She was treated with high doses of inhaled steroids and bronchodilators, systemic steroid and anti-leukotrienes, without improvement; with multiple hospitalizations due to severe asthma exacerbations. During its evolution, the patient presented maxillary and ethmoid sinusitis, hypereosinophilia up to 30%, migratory pulmonary nodules, livedo reticularis and Raynaud’s phenomenon. She had negative antineutrophil cytoplasmic antibodies but diagnosis of eosinophilic granulomatosis with polyangiitis was established and management starts with methotrexate, nifedipine, mycophenolic acid, cyclophosphamide and systemic steroid with partial response, without achieving asthma control neither reduce joint pain, very significantly affecting the quality of life. Omalizumab treatment 300 mg every 15 days for 4 months was added. Results: After fourth dosis, asthma control was achieved from 12 to 20 points in asthma control test and improvement in spirometry values from FEV1 / FVC 72% to 80%, decrease in arthralgia, eosinophil count to 2% and serum IgE levels from 239 to 100 IU/ml. Keeping itself free of asthma exacerbations during treatment and allowing decreased inhaled budesonide 1,000 mcg to 640 mcg, without presenting any adverse reactions. Conclusion: Omalizumab treatment in this pediatric patient resulted safe and effective.
P164 CYSTIC FIBROSIS MUTATION AND PRIMARY CILIARY DYSKINESIA PATHOLOGY PRESENTING AS RECURRENT SINOPULMONARY INFECTIONS AND AZOOSPERMIA E. Feldman*1, P. Parikh2, 1. Flushing, NY; 2. New York, NY. Introduction: There are documented cases of clinically mild cystic fibrosis (CF) with congenitally absent vas deferens. The gene involved (TG)12-5T is classically a autosomal recessive gene. Primay ciliary dyskenisa (PCD) is also linked to azoospermia. To our knowledge, this is the first case of a patient with symptoms of clinically mild CF with only one of two genes affected as well as pathologic and clinical findings of PCD on ciliary biopsy. Methods: Case presentation Results: A 40 year old male presented for several year history of recurrent sinusitis and pulmonary infections since childhood as well as azospermia. Quantitative immunoglobulins tested revealed low IgG (627 ug/ mL [700-1600]) and IgM (27 ug/mL [40-230]) levels. All vaccine titers were normal and he responded to the pneumococcal vaccine. He was subsequently evaluated by an otolaryngologist who performed a nasal biopsy. The pathology showed absent microtubular structures on both light and electron microscopy. Further genetic testing revealed a single gene variant of CTFR gene mutation (TG) 12-5T. He had no additional gene mutations in the CF or PCD spectrum. His chloride sweat test results were indeterminant. Conclusion: This patient presented with only gene mutation of what is otherwise known to be an autosomal recessive condition with mild CF symptoms and congenitally absent vas deferens. In addition, his pathology findings of abnormal microtubular structures are suggestive of PCD however he lacks any known PCD gene mutation. This is the first case of what appears to be a mixed form of both clinical syndromes.
Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 117 (2016) S22eS124
Odds of a diagnosis of OSA by asthma control and ICS use
P162 THE ALLERGIST, CHRONIC COUGH AND UPPER AIRWAY COUGH SYNDROME T. Nsouli*1, N. Diliberto2, A. Nsouli1, C. Davis1, K. Cofsky1, J. Bellanti1, 1. Washington, DC; 2. washington, DC. Introduction: Chronic cough (CC) is the most frequent symptom for which patients seek medical care and among the most perplexing and frustrating disease provoking diagnostic challenges for the clinician. One of the frequent causes of CC is postnasal drip. The Practice Guidelines, however, recommend replacing the term postnasal drip syndrome with upper airway cough syndrome (UACS) (Pratter MR. Chest. 2006;129:63S). This study explores the etiologies of CC and treatment options for patients referred to our allergy-immunology clinic. Method: Using The Expert Panel Report on Cough (Lewis SZ, et al. Chest 2014; 146: 1395), study patients were randomized on the basis of clinical history, physical examination, allergy skin prick tests, spirometry, FeNO, appropriate imaging, and others. Results: A total of 137 patients with CC (age 9-68 yr, mean age 32 yr, 72 females, 65 males), with median cough duration of 1.2 years were entered into the study. The etiologic classification of CC in the study population was as follows: 33.57% cough variant asthma, 24.08% UACS, 21.60% LPR/GERD, 15.32% allergic asthma, 8.75% habit cough, 8.02% post-infectious, 6.56% chronic bronchitis, 5.83% cough associated with ACE-I, 4.37% bronchiectasis, 2.91% eosinophilic bronchitis and 6.56% unknown origin. Each condition existed alone or in combination. A carefully crafted treatment resolved CC in 92% of patients. Conclusion: This study further supports the role of UACS in CC and, with allergic asthma and LPR/GERD, forms the most frequent contributors to cough. It also underscores the overlapping etiologic features of the condition and highlights the role of the allergistimmunologist in unraveling the diagnostic challenge.
P163 OMALIZUMAB TREATMENT IN TEEN PATIENT WITH SEVERE ASTHMA AND EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS: CASE REPORT D. Garcia Fajardo*1, H. Perez2, B. Del Rio Navarro3, O. Saucedo Ramirez3, J. Del Rio-Chivardi3, E. Rodriguez3, 1. Rioverde, SL, Mexico; 2. Menda, YU, Mexico; 3. Mexico City, DF, Mexico.
Introduction: The formely Churg-Strauss syndrome is extremely rare in children, ANCAS are positive only in 25% of pediatric patients, most commonly affects the lungs. We present the case of a teenager diagnosed with severe asthma due to this syndrome with poor response to treatment and subsequent clinical improvement after omalizumab treatment. Case: Female 13 years old diagnosed with asthma with poor control of symptoms, classified as severe asthma. She was treated with high doses of inhaled steroids and bronchodilators, systemic steroid and anti-leukotrienes, without improvement; with multiple hospitalizations due to severe asthma exacerbations. During its evolution, the patient presented maxillary and ethmoid sinusitis, hypereosinophilia up to 30%, migratory pulmonary nodules, livedo reticularis and Raynaud’s phenomenon. She had negative antineutrophil cytoplasmic antibodies but diagnosis of eosinophilic granulomatosis with polyangiitis was established and management starts with methotrexate, nifedipine, mycophenolic acid, cyclophosphamide and systemic steroid with partial response, without achieving asthma control neither reduce joint pain, very significantly affecting the quality of life. Omalizumab treatment 300 mg every 15 days for 4 months was added. Results: After fourth dosis, asthma control was achieved from 12 to 20 points in asthma control test and improvement in spirometry values from FEV1 / FVC 72% to 80%, decrease in arthralgia, eosinophil count to 2% and serum IgE levels from 239 to 100 IU/ml. Keeping itself free of asthma exacerbations during treatment and allowing decreased inhaled budesonide 1,000 mcg to 640 mcg, without presenting any adverse reactions. Conclusion: Omalizumab treatment in this pediatric patient resulted safe and effective.
P164 CYSTIC FIBROSIS MUTATION AND PRIMARY CILIARY DYSKINESIA PATHOLOGY PRESENTING AS RECURRENT SINOPULMONARY INFECTIONS AND AZOOSPERMIA E. Feldman*1, P. Parikh2, 1. Flushing, NY; 2. New York, NY. Introduction: There are documented cases of clinically mild cystic fibrosis (CF) with congenitally absent vas deferens. The gene involved (TG)12-5T is classically a autosomal recessive gene. Primay ciliary dyskenisa (PCD) is also linked to azoospermia. To our knowledge, this is the first case of a patient with symptoms of clinically mild CF with only one of two genes affected as well as pathologic and clinical findings of PCD on ciliary biopsy. Methods: Case presentation Results: A 40 year old male presented for several year history of recurrent sinusitis and pulmonary infections since childhood as well as azospermia. Quantitative immunoglobulins tested revealed low IgG (627 ug/ mL [700-1600]) and IgM (27 ug/mL [40-230]) levels. All vaccine titers were normal and he responded to the pneumococcal vaccine. He was subsequently evaluated by an otolaryngologist who performed a nasal biopsy. The pathology showed absent microtubular structures on both light and electron microscopy. Further genetic testing revealed a single gene variant of CTFR gene mutation (TG) 12-5T. He had no additional gene mutations in the CF or PCD spectrum. His chloride sweat test results were indeterminant. Conclusion: This patient presented with only gene mutation of what is otherwise known to be an autosomal recessive condition with mild CF symptoms and congenitally absent vas deferens. In addition, his pathology findings of abnormal microtubular structures are suggestive of PCD however he lacks any known PCD gene mutation. This is the first case of what appears to be a mixed form of both clinical syndromes.