A 30-year-old man with chronic asthma has worsening control despite adequate inhaled therapy. He expectorates brownish-black mucous plugs. Total serum IgE is 1600 IU/mL, Aspergillus fumigatus specific IgE is positive, and HRCT shows central, proximal varicose bronchiectasis with mucoid impaction. What is the most appropriate next step in management?
- A Doubling the dose of inhaled corticosteroid alone
- B Itraconazole monotherapy for 16 weeks
- C Oral corticosteroids such as prednisolone 0.5 mg/kg/day ✓
- D Omalizumab as first-line therapy
Explanation
This is allergic bronchopulmonary aspergillosis: asthma, high total IgE (usually over 1000 IU/mL), Aspergillus sensitisation, central bronchiectasis, and plug expectoration. The mainstay of treatment is oral corticosteroids, which suppress the hypersensitivity response; itraconazole is added in relapsing or steroid-dependent disease, not as monotherapy. Doubling inhaled steroid does not address the systemic eosinophilic inflammation, and omalizumab is a later-line option. The discriminating fact is that ABPA is treated primarily as a corticosteroid-responsive disease.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.