Jiaci

Practitioner's Corner

J Investig Allergol Clin Immunol 2019; Vol. 29(5): 378-398

consolidation, areas of ground-glass opacity, micronodules,

and tree-in-bud opacities. Esophagogastroscopy showed a

dilated esophagus. Esophageal high-resolution manometry

revealed a hypertensive lower esophageal sphincter that did not

relax on swallowing; similarly, there was no peristaltic wave

in the esophagus. The patient was diagnosed with achalasia.

When the test results had been collected and the medical

history was being completed, the patient reported that for

at least 3 years, she had experienced nocturnal vomiting

containing undigested food; her nasal discharge had also

contained food particles. The symptoms were associated with

persistent cough.

Once the diagnosis of achalasia was confirmed, the patient

was referred for surgery (peroral endoscopic myotomy). A

check-up 2 months after surgery revealed that cough, dyspnea,

rhinorrhea, and nocturnal vomiting had considerably abated.

All asthmatic medications were discontinued. Spirometry

results returned to normal values (FEV

, 3.89 L [121%]; FVC,

4.3 L [117%]; FEV

/FVC, 90%). The result of the methacholine

challenge test performed at that time was negative.

The present case concerns a patient with respiratory

symptoms resulting from achalasia that were misdiagnosed as

severe asthma. In fact, the symptoms reported were caused by

recurrent aspiration of small amounts of gastric content that

occurred largely at night over a period of a few years. The chest

CT scans performed on admission to the Allergy Department

were characteristic of bronchiolitis and reflected chronic

bronchiolocentric inflammation caused by recurrent aspiration.

The clinical picture and imaging scans pointed to a diagnosis

of diffuse aspiration bronchiolitis (DAB) complicated by

incidents of aspiration pneumonia. The term diffuse aspiration

bronchiolitis was first used by Matsuse et al [4] as a name

for a chronic inflammation of the bronchioles produced by

frequent aspiration of foreign particles. Although DAB is

usually diagnosed in the elderly, it has been reported in younger

patients, with clinical manifestations similar to those found in

the elderly [5-8]. In younger patients, the major risk factors

responsible for DAB are dysphagia due to achalasia and

gastroesophageal reflux disease with concomitant recurrent

aspiration.

In the case we report, the diagnostic delay may have

been caused by various factors. First, apart from a 5-year

history of vomiting that was erroneously interpreted as a

consequence rather than the cause of coughing, there were no

accompanying symptoms characteristic of achalasia. Second,

auscultatory phenomena were interpreted as asthmatic

wheezing, while they might in fact have resulted from

pressure on the trachea and/or bronchiolitis, which can also be

responsible for variations in airflow obstruction in spirometry.

Third, achalasia is a rare disorder, diagnosed mostly in elderly

adults (generally during the sixth decade of life, with an

estimated prevalence and incidence, respectively, of 10.82

cases per 100 000 and 1.63 cases per 100 000 [9]). Fourth, the

primary symptoms of achalasia are mostly gastrointestinal,

whereas respiratory symptoms are less frequent. In up

to 40% of cases of achalasia, pulmonary disorders such

as cough, wheezing, and recurrent aspiration can occur,

although DAB is very rare [10]. Bronchiolitis associated

with chronic aspiration can considerably hamper diagnosis.

DAB should be considered in patients with respiratory

symptoms such as chronic cough, wheezing, obstruction,

persistent radiologic abnormalities in high-resolution CT, and

a high risk of aspiration. Given the scope of the respiratory

changes we report, the possible consequences of a further

delay in surgical treatment of achalasia could be serious.

Our findings confirm the prevailing stance of asthma experts

who claim that if asthma symptoms persist despite intensive

pharmacological treatment, it is advisable to revisit the

patient’s clinical history, bearing in mind the possibility of

a diagnosis that mimics asthma.

Funding

The authors declare that no funding was received for the

present study.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References

1. Chung KF, Wenzel SE, Brozek JL, Bush A, Castro M, Sterk PJ,

et al. International ERS/ATS guidelines on definition, evaluation

and treatment of severe asthma. Eur Respir J. 2014;43:343-73.

2. Kim S, Lee CH, Jin KN, Cho SH, Kang HR. Severe asthma

phenotypes classified by site of airway involvement and

remodeling via chest CT scan. J Investig Allergol Clin Immunol.

2018;28(5):312-20.

3. Robinson DS, Campbell DA, Durham SR, Pfeffer J, Barnes PJ,

Chung KF. Systematic assessment of difficult-to-treat asthma.

Eur Respir J. 2003;22:478-83.

4. Matsuse T, Oka T, Kida K, Fukuchi Y. Importance of diffuse

aspiration bronchiolitis caused by chronic occult aspiration in

the elderly. Chest. 1996;110:1289-93.

5. Akritidis N, Gousis C, Dimos G, Paparounas K. Fever, cough,

and bilateral lung infiltrates: achalasia associated with

aspiration pneumonia. Chest. 2003;123:608-12.

6. Matsuse T, Teramoto S, Matsui H, Ouchi Y, Fukuchi Y.

Widespread occurrence of diffuse aspiration bronchiolitis

in patients with dysphagia, irrespective of age. Chest.

1998;114(1):350-1.

Figure.

Computed tomography scan showing massive dilatation of the

esophagus and tracheal compression.

395