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.
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).