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 60-yr-old woman referred for a 5-yr history of severe asthma on 18th August 2010. Cough and dyspnea were her main symptoms. Her initial FEV1 was 0.88 L (42.9%), FVC was 1.10 L (44.9%), and FEV1/FVC was 73.4% without a BD response. A crackling sound was heard in both lungs. A chest CT showed diffuse bronchial wall thickening and centrilobular nodules with a tree-in-bud appearance in both lower lungs (). Induced sputum showed 2% eosinophils. A MBPT could not be performed. Water's view showed bilateral maxillary sinusitis. She had been using inhaled budesonide combined with formoterol, a tiotropium inhaler, montelukast, and theophylline for a month. After a month, she complained of continuous cough and sputum. The crackling sound was consistently heard. The AFB studies were negative, and clarithromycin was introduced. The patient took clarithromycin 250 mg twice a day for 5.5 months with asthma medication, after which her FEV1 improved from 0.88 L (42.9%) to 1.96 L (97.1%), and FVC improved from 44.9% to 98.8%. Follow-up chest CT after a year showed improved centrilobular nodules in both lungs. She was able to discontinue budesonide and formoterol.