Allergy Case Study: 34 yr. old Male Presenting with Symptoms of Asthma; Spirometry is Normal

Patient is a 34 year-old male who presents with coughing, wheezing, shortness of breath and chest tightness with exertion.  His symptoms have been noted to be getting progressively worse over the past 6 months.  He also reports wheezing and prolonged coughing with upper respiratory infections.  Prior allergy testing was positive for an allergy to dust mites, tree pollen, grass pollen, cat dander and dog dander.  He does not have any pets at home but does have a girlfriend with a cat.  He reports mild seasonal allergies in the spring.  ROS is positive for GERD.

Past Medical History:
PAR/SAR/AC
GERD

Current Medications:
Pepcid 20mg QD prn
Allegra 180mg QD prn

Allergies:
NKDA

Family History:
Positive for atopy – Grandfather with asthma.  Parents with Allergic Rhinitis

Environmental Survey:
Negative for pets, but girlfriend with a cat.  Negative for smokers.  Area rug in the bedroom. Occupation: Desk job – finance industry.

Diagnostic Tests Performed with the MiniBox+:
Results shown are from the Patient Report

(click for larger view)

Spirometry – within normal limits.  FEV1 = 115%.  FEV1% = 101%.  FEF25-75 = 116%.

Lung Volumes: TLC= 123%, RV = 176%

FENO = 12 ppb

Assessment & Plan:

This 34-year-old male has two separate risk factors for asthma – Allergic Rhinitis and GERD. In addition, his clinical history is suggestive for asthma.  However, spirometry and FENO results are within normal limits.  Lung volume measurements were taken, demonstrating elevated Residual Volume (RV), indicating significant air trapping and resulting in increased dead space.  This is an indicator of asthma.

The following recommendations were made to the patient:

1. GERD
   1. Discontinue Pepcid
   2. Initiate treatment with Prilosec 20mg QAM
   3. Dietary modifications
   4. Weight loss
2. Allergic Rhinitis
   1. Dust mite precautions in the home
   2. Minimize exposure to the cat dander at girlfriends home.  Ideally the cat would be removed from the home.  At a minimum, recommend she place a HEPA filter in her home and not allow the cat in the rooms where the patient spends most of his time.
   3. Allergen Immunotherapy
3. Mild Persistent Asthma
   1. Alvesco 160 one puff BID via an Aerochamber
   2. Albuterol HFA two puffs Q4 hours prn via an Aerochamber.
   3. Return to the office in 4-6 weeks to monitor response.

Follow up:

The patient returned to the office 6 weeks later.  He was compliant with treatment.  He instituted dust mite precautions in the home and the girlfriend placed a HEPA filter in her home.  He also modified his diet and took the Prilosec for 6 weeks.  He was compliant with the Alvesco.  He reported a significant improvement in his respiratory symptoms.  He no longer developed symptoms with exertion.  He did not develop an upper respiratory infection in the interim.  Repeat Pulmonary Function Testing was improved, with the Residual Volume normalizing to 110%.  FEV1, FEV1%, FEF25, 75 and FENO all remained within normal limits.  At the follow up visit he agreed to start Allergen Immunotherapy.  In addition, the dose of Alvesco was lowered to 80 one puff BID with follow up scheduled for 3 months.

Conclusion:

The performance of lung volume measurements in the office provided additional information that enabled a diagnosis of asthma despite normal spirometry and FeNO results.

Submitted by Dr. Jeffrey Weiss, Allergy & Immunology, Riverdale NJ