‘There is more to this than meets the eye.’ I used to think that this was just a turn of phrase; however, after joining a medical career it became a living truth for me. A recent example will suffice.

A 54 year old lady, presented to me last week, with a history of long standing asthma for the last 18 years. It was poorly controlled and managed, with her requiring frequent nebulization therapy and repeated short courses of oral steroids. She appeared to be chronically malnourished and indeed, on examination, her BMI was 17 kg/sq m. One often forgets, in this modern era of inhaled bronchodilators, what asthma can do to a person. She was a small reminder that we are only one step above the previous generation in the treatment of this disease. Although much research is going on, except for the reliable beta agonists and corticosteroids, the other medicines available are insufficient to control asthma on their own.

Coming back to the case; after taking the history and examining her – to repeat myself again – I thought “There is more to this than meets the eye” and ordered further workup. Lo and behold, she came a week later with an X-ray full of alveolar and interstitial opacities. Our patient was accompanied by her brother, who was an X-ray technician. Now, there is a tendency in our part of the world to attribute almost all X-ray abnormalities to tuberculosis, and more so in medical and para-medical staff. Even worse, this gentleman was a veteran radiographer, with over 15 years experience. I had a hard time convincing him of further workup; throughout  the consultation he kept looking at me out of the corner of his eye!

Anyway, they came after a few days with an HRCT of the chest and serological investigations. I was pleased to see that my hunch was right and she was finally diagnosed to have ABPA or Allergic broncho-pulmonary aspergillosis, which is much prevalent in this area. Her brother was all smiles!!

ABPA or allergic bronchopulmonary mycosis (ABPM) is an allergic reaction to colonization of the airways by fungal elements, most commonly Aspergillus species ( hence, commonly ABPA rather than ABPM!) It affects a substantial portion of asthmatics, especially those suffering from severe or difficult to control asthma. The diagnostic criteria are still evolving; also there is no clarity on whom to screen for the disease. The pointers in this case were: