A 71-yr-old woman referred for a 10-yr history of cough, dyspnea, sputum, post-nasal drip on 4th June 2010. Her breathing sound was clear. A chest x-ray (CXR) showed increased bronchovascular markings in the both lower lungs and consolidation in the left lower lung field (LLLF) (). Initial forced expiratory volume in 1 second (FEV1) was 1.21 L (64.9%) and forced vital capacity (FVC) was 1.70 L (75.5%) and FEV1/FVC was 71.1% without a bronchodilator (BD) response. The methacholine bronchial provocation test (MBPT) was positive as a result of provocative concentration (PC20) was 3.8 mg/mL. Induced sputum showed mild eosinophilia (3%). During one month of asthma treatment with inhaled budesonide combined with formoterol, theophylline, and montelukast, she complained of mild fever and yellowish sputum. Thus, we performed a chest CT and water's view x-ray. Bilateral maxillary sinusitis was observed (). CT showed bronchial wall thickening with centrilobular nodules, which was suggestive of DPB (). To differentiate from mycobacterial infection (), acid fast bacilli (AFB) studies were done and showed negative. The patient took clarithromycin 250 mg twice a day for 9 months, after which her FEV1 improved from 64.9% to 84.2%, FVC and FEV1/FVC also improved. A follow-up examination, LLLF consolidation and sputum eosinophilia disappeared. In addition, she was able to reduce the daily amount of inhaled steroid and discontinue theophylline.
A 52-yr old man visited for a 4-yr history of cough, dyspnea, sneezing, rhinorrhea, and wheezing on 25th June 2010. Initial FEV1 was 1.74 L (54.4%), FVC was 2.40 L (61.3%), and FEV1/FVC was 72.5%. BD response was positive (FEV1 increased 20.6%, 270 mL). CXR showed multiple nodules in both lungs. A sinus CT showed bilateral maxillary sinusitis. A chest CT showed a tree-in-bud appearance and air trapping in both lower lungs. Induced sputum showed neutrophilia. He showed a poor response to inhaled budesonide combined with formoterol and montelukast. As AFB studies were negative, we administered clarithromycin. The patient took clarithromycin 250 mg twice a day for 9 months, after which FEV1 improved from 54.4% to 95.3%, FVC improved from 61.3% to 92.8%, and FEV1/FVC also improved. Cough and sputum disappeared. He now takes montelukast and clarithromycin without respiratory symptoms.