Occam's razor or Hickam's dictum? Allergic bronchopulmonary aspergillosis and eosinophilic granulomatosis with polyangiitis*

Anand Shah and Scott R Henderson (AS and SRH): a 72-year-old retired male physician was referred with poorly controlled asthma, necessitating oral glucocorticoid therapy. He had been diagnosed with occupational asthma 9 years earlier with initially good control on an inhaled corticosteroid (ICS). In the preceding year, his symptoms deteriorated with increasing wheeze, dyspnoea and persistent productive cough with 5 mL sputum daily associated with reduced exercise tolerance of 30–50 metres on the flat. He also reported a postnasal drip and allergic rhinitis. Medical history included two nasal polypectomies and paroxysmal tachycardias, with normal 24 h Holter, echocardiogram and exercise tolerance test.He had previously worked as an occupational physician for 15 years, monitoring coffee bean handlers for asthma and sensitivity to Aspergillus spp, commonly found in coffee bean cargoes. Interestingly, he himself was indirectly exposed to coffee bean dust (including green coffee beans prior to roasting and castor bean dust) through his interaction with workers and his place of work. He then developed asthma symptoms 6 years after taking up his Occupational Physician post, consistent with a diagnosis of occupational asthma, and a series of skin prick tests demonstrated sensitivity to Aspergillus fumigatus .Examination at presentation revealed no significant abnormalities. Investigations showed FEV1 of 1.5 L (45% predicted), FVC of 3.0 (63% predicted) and peak expiratory flow (PEF) of 280 L/min (predicted). Sputum cytology revealed 12% eosinophils. Total IgE was elevated at 219 (0–120) kU/L with Aspergillus radioallergosorbent test (RAST) at 4.05 (0–0.34) IU/mL. Peripheral eosinophil count, on prednisolone, was normal. Skin prick tests were positive to A. fumigatus , grass mixture and house dust mite. Chest radiograph was unremarkable.Philip W Ind (PWI): lung function tests demonstrated an obstructive defect with an FEV1:FVC ratio of 50% and reduced PEF. In addition to probable IgE-related occupational asthma, his previous allergen exposure, documented immune reactivity …