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Practitioner's Corner
J Investig Allergol Clin Immunol 2019; Vol. 29(5): 378-398 © 2019 Esmon Publicidad
Manuscript received March 28, 2019; accepted for publication
May 7, 2019.
Mariana Couto
Immunoallergology, José de Mello Saúde
Portugal
E-mail:
Treating “Asthma” With A Scalpel: Achalasia
Mimicking Asthma
Nittner-Marszalska M, Kopeć A, Jędrzejewska J, Pawłowicz R
Department of Internal Medicine and Allergology, Wroclaw
Medical University, Wroclaw, Poland
J Investig Allergol Clin Immunol 2019; Vol. 29(5): 394-396
doi: 10.18176/jiaci.0417
Key words: Asthma. Diffuse aspiration bronchiolitis. Achalasia.
Palabras clave: Asma. Bronquiolisis difusa por aspiración. Acalasia.
When asthma remains partially controlled or even
uncontrolled despite qualified treatment, experts stress the
need to verify the diagnosis and rule out conditions that can
mimic asthma [1,2]. According to some reports, misdiagnosis
of nonasthmatic conditions treated as uncontrolled asthma is
as frequent as 12%-30%; hence, a certain degree of skepticism
is recommended [3].
An 18-year-old woman was referred to our Allergy
Department with a diagnosis of severe asthma. Her asthma was
partially controlled and sometimes uncontrolled, with signs of
bronchial obstruction that persisted despite intensive treatment
(GINAguidelines, step 5: daily doses of fluticasone propionate
1000 µg and salmeterol 100 µg, with prednisone 20-40 mg/d
for 5-7 d every second or third month). Since the onset of
her disease (age 13 years), the main symptoms were cough,
breathlessness, and wheezing that occurred predominantly at
night, causing frequent nocturnal awakening. She also reported
rhinorrhea during sleep. The patient’s mother described the
nocturnal symptoms as “noisy breathing”. During the last
2 years, the patient had pneumonia twice, and several episodes
of “bronchitis” treated with antibiotics. The patient denied
having experienced paroxysmal dyspnea, exercise-triggered
dyspnea, or dyspnea induced by other factors (specific or
nonspecific). Similarly, she did not report any other symptoms,
particularly gastric symptoms. She was sensitized to house
dust mite, but had no family history of atopy or asthma and
had never smoked cigarettes.
Physical examination and laboratory test results during
hospitalization revealed no abnormalities. Spirometry
confirmed a moderate obstructive picture (FEV1, 1.92 L
[59.7%]; FVC, 3.61 L [98.2%]; FEV 1/FVC, 53.2%).
Postbronchodilator spirometry revealed lack of response to
inhaled bronchodilators. Body plethysmography showed
elevated airway resistance, both inspiratory and expiratory
(respectively 305% and 300% of predicted) and increased
residual volume (254%). Blood gasometry and FeNO (7 ppb)
were normal. Neither sputum eosinophilia nor nasal discharge
were recorded. The blood eosinophil count was normal. Chest
radiograph findings were unremarkable. The chest CT scan
revealed a massively dilated esophagus filled with food residue
and, consequently, tracheal compression (Figure). It also
revealed parenchymal lung changes in the form of distal diffuse
6. Arroabarren E,Alvarez-García J,Anda M, de Prada M, Ponce C,
Alvarez-Puebla MJ. Impact of Specific Training in Anaphylaxis
for Triage Nursing Staff in the Pediatric Emergency Department
of a Tertiary Hospital. J Investig Allergol Clin Immunol.
2018;28(3):401-6.
7. Couto M, Silva D, Marques D, Paiva M, Jacinto T, Câmara
R. Allergic diseases in sports. Rev Port Imunoalergologia.
2017;25(4):259-75.
8. Valero A, Olaguibel J, Delgado J, Plaza V, Álvarez F, Molina J, et
al. Dilemmas and New Paradigms in Asthma Management. J
Investig Allergol Clin Immunol. 2019;29(1):15-23.
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