title: Dyspnea, wheezing, and airways obstruction: is it asthma?
abstract: Dyspnea, wheezing, and decreased FEV1 with bronchodilator response are characteristic of asthma. However, when standard asthma therapy fails, a broad differential must be considered to avoid a catastrophic outcome. This article presents a case report of a 48-year-old Filipino woman, who was referred for evaluation of cough, dyspnea and wheezy respiration, changes in voice quality, nasal and palatal pruritus, and postnasal drainage. She was found to have mold spore hypersensitivity and abnormal spirometry with an obstructive pattern and a 15% reversibility postnebulized albuterol. An initial diagnosis of allergic rhinitis and adult-onset asthma was made, and therapy was initiated which included: salmeterol, budesonide, montelukast, and pirbuterol. Her symptoms persisted and rabeprazole was added to treat possible laryngopharyngeal reflux. Repeat spirometry demonstrated worsening obstruction. There was no improvement with systemic corticosteroids. High-resolution computed tomography of the chest demonstrated a left paratracheal mass, obstructing 60% of the airway. Bronchoscopy revealed a tumor 4-5 cm below the vocal cords with the appearance of adenoid cystic carcinoma, which was confirmed by pathology. All symptoms resolved and spirometry normalized with resection of mass and radiation therapy. Adenoid cystic carcinoma (ACC) is an uncommon form of malignant neoplasm that arises from salivary glands. Tracheobronchial ACC typically presents with symptoms of cough, dyspnea, and hoarseness. ACC has a relatively indolent course. Standard therapy is surgical resection often followed by radiotherapy. In patients who fail conventional therapies for asthma, it is important to consider other diagnoses to avoid fatal outcomes.
authors.affiliation: Division of Allergy, Asthma, and Immunology, Scripps Clinic, 10666 North Torrey Pines Road, Mail drop W205, La Jolla, CA 92037, USA.
authors.forename: Purvi K
authors.initials: PK
authors.lastname: Mehra
authors.forename: Katharine M
authors.initials: KM
authors.lastname: Woessner
mesh_terms: D000402:Airway Obstruction / Q000150:complications / Q000209:etiology; D001249:Asthma / Q000150:complications / Q000175:diagnosis*; D003528:Carcinoma, Adenoid Cystic / Q000150:complications / Q000175:diagnosis*; D003937:Diagnosis, Differential; D004417:Dyspnea / Q000150:complications; D005260:Female; D006801:Humans; D008875:Middle Aged; D012135:Respiratory Sounds; D014134:Tracheal Neoplasms / Q000150:complications / Q000175:diagnosis*