Unexpected cause of poorly controlled bronchial asthma.

We present the case of a 41-year-old non-smoker woman. She has been diagnosed with moderate bronchial asthma for about 15 years and is being treated with medium-dose budesonide/formoterol and montelukast. She has been well controlled, but in last months and following an exacerbation, has worsened.

Laboratory tests were normal, including IgE. Chest X-ray showed no significant alterations. Spirometry: FVC 1910 ml (57%); FEV1 1690 ml (61%), FEV1/FVC 84%.

Initially, inhaled treatment was changed to high-dose beclomethasone/formoterol, and tiotropium. She came two months later, reporting partial improvement (ACT test score 17), but the reduced spirometric pattern persisted. Given the poor clinical response despite treatment, a chest CT scan was requested. Chest CT: pulmonary hyperclarity with less vascularisation in the left hemithorax, compatible with a hyperinflation effect. An endobronchial tumour of 10mm is visualised in the left main bronchus, compatible with a bronchial carcinoid as the first diagnostic option.

Fig. 1  

A bronchoscopy was then performed, in which a stenotic mass with a soft consistency, smooth and friable surface was observed at the end of the left main bronchus, which was biopsied ([Fig. 2]) without being able to go beyond the lesion. The result of the bronchial biopsy was a carcinoid tumour with histological characteristics of a typical carcinoid.

Fig. 2  

The patient is currently pending evaluation by Chest Surgery and by our Interventional Bronchoscopy Unit; as cases of typical, pedunculated and clearly intrabronchial carcinoid tumours may require endoscopic resection. We find this case report very interesting, as the patient's history of bronchial asthma could possibly have delayed the diagnosis, as the symptoms of carcinoid tumours (cough, wheezing, repeated infections...) are similar to those of chronic respiratory diseases. In addition, these tumours usually appear in young, non-smoking patients, as in our case, which also means that the degree of suspicion is low. CT imaging was decisive in this case, although bronchoscopy is the main diagnostic method. In cases of patients with asthma or COPD, with persistent symptoms despite correct treatment, a bronchoscopic examination should be carried out to rule out the possibility of these centrally located neuroendocrine tumours.

 

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Publication History

Article published online:
09 March 2023