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 69-yr-old man came with a 3-yr history of cough, sputum, and dyspnea on 11th July 2012. His initial FEV1 was 1.88 L (79.2%), FVC was 2.34 L (76.8%), and FEV1/FVC ratio was 80.3%. FEV1 increased 13.2% (250 mL) after bronchodilator inhalation. Induced sputum showed neutrophilia without eosinophils. CXR showed tiny nodules and bronchial wall thickening in both lower lungs (). Water's view showed left maxillary sinusitis (). A chest CT showed severe and diffuse centrilobular nodules and branching linear opacities in both lungs (). The AFB studies were negative. He was prescribed fluticasone combined with salmeterol, pranlukast, myrtol, and clarithromycin. After the patient took clarithromycin 250 mg twice a day for 40 days, his cough and sputum decreased. A follow-up CT showed a slight decrease in bronchial wall thickening and multiple nodules throughout both lungs (). After 8 months of clarithromycin, he was able to use only fluticasone and salmeterol inhaler with clarithromycin. His FEV1 increased from 79.2% to 127.0%, and FVC increased from 76.8% to 118.9%.\nThe study occurred in the allergy clinic of a tertiary teaching hospital in Korea. We collected 5 patients who visited as severe asthma but treated well with DPB treatment. Institutional review board reviewed and approved this study (4-2014-0362).