Response

Editor – We would like to thank the correspondents for their interest in our case report. We are in complete agreement that this case illustrates the difficulty in diagnosing the various respiratory conditions that can be caused by Aspergillus and the considerable overlap between them. We also agree that the distinction between non-invasive and invasive forms of Aspergillus tracheobronchitis is important and in our case, the disease was non-invasive.

We read with interest their comments that allergic bronchopulmonary aspergillosis (ABPA) has been reported in individuals without a history of asthma,¹ and whether this patient had developed ABPA rather than Aspergillus tracheobronchitis as we proposed. ABPA was one of the differential diagnoses considered while the patient was under our care; however several factors influenced our final diagnosis, based on the diagnostic criteria of Rosenberg and Patterson.^2,3

Radiologically, no fleeting opacities or bronchiectasis were present on chest radiograph or computed tomography of the chest. In this case, the radiological manifestation of disease was limited to right middle lobe collapse, which subsequently resolved. While he did develop features of allergic sensitisation to Aspergillus – demonstrated by raised total serum IgE, Aspergillus specific IgE and serum eosinophilia – we felt this was a consequence of his exposure to a significant burden of Aspergillus spores, as demonstrated by the fungal hyphae from his mucous plug. Finally, his response to treatment was more rapid than is usually seen in ABPA.

We would like to thank the correspondents for highlighting that ABPA can rarely be seen in patients without a diagnosis of asthma or cystic fibrosis, further illustrating the complexity of Aspergillus-related pulmonary disease.