title: Centrilobular opacities in the asthmatic lung successfully treated with inhaled ciclesonide and tiotropium: with assessment of alveolar nitric oxide levels.
abstract: BACKGROUND
  Despite the fact that bronchioles are involved in asthma, there have been limited asthmatic cases showing marked centrilobular opacities on computed tomography (CT) chest scans. Systemic corticosteroids have been administered in such cases, but the efficacy of extra-fine particle inhaled corticosteroids has not been assessed.
  
  
  METHODS
  A previously healthy 64-year-old man presented with a four-month history of productive cough and progressive dyspnea despite a combination therapy with inhaled salmeterol (50 μg bid) and fluticasone (500 μg bid), sustained-release theophylline, and pranlukast because of suspicion of asthma. Physical examination revealed wheezing at the end of forced expiration. High resolution CT chest scan showed diffuse centrilobular opacities, bronchiectatic changes, and bronchial wall thickening. Transbronchial lung biopsy, bronchoalveolar lavage fluid, and transbronchial biopsy all showed predominant eosinophil infiltrates, suggesting that eosinophilic inflammation across the entire airway tree caused the abnormal CT findings. Alveolar fraction of exhaled nitric oxide level, a non-invasive marker of eosinophilic peripheral airway inflammation, was also elevated. Because he refused systemic corticosteroids, inhaled ciclesonide (400 μg bid) and inhaled tiotropium were added on to his current medication under careful observation. His symptoms, pulmonary function and CT findings promptly improved, and he had fully recovered at follow-up.
  
  
  CONCLUSIONS
  Extra-fine particle inhaled corticosteroids could be an alternative approach in centrilobular opacities caused by eosinophilic peripheral airway inflammation.
authors.affiliation: Department of Respiratory Medicine, Kyoto University, Japan.
authors.forename: Hirofumi
authors.initials: H
authors.lastname: Kiyokawa
authors.forename: Hisako
authors.initials: H
authors.lastname: Matsumoto
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Nakaji
authors.forename: Akio
authors.initials: A
authors.lastname: Niimi
authors.forename: Isao
authors.initials: I
authors.lastname: Ito
authors.forename: Kikuko
authors.initials: K
authors.lastname: Ono
authors.forename: Tomoshi
authors.initials: T
authors.lastname: Takeda
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Oguma
authors.forename: Kojiro
authors.initials: K
authors.lastname: Otsuka
authors.forename: Michiaki
authors.initials: M
authors.lastname: Mishima
mesh_terms: D018926:Anti-Allergic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D001249:Asthma / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000473:pathology; D004804:Eosinophils / Q000473:pathology; D006801:Humans; D001239:Inhalation; D008168:Lung / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D009569:Nitric Oxide / Q000032:analysis* / Q000378:metabolism; D011282:Pregnenediones / Q000008:administration & dosage / Q000627:therapeutic use*; D011650:Pulmonary Alveoli / Q000378:metabolism* / Q000473:pathology; D012602:Scopolamine Derivatives / Q000008:administration & dosage / Q000627:therapeutic use*; D000069447:Tiotropium Bromide; D014057:Tomography, X-Ray Computed
chemical_list: D018926:Anti-Allergic Agents; D011282:Pregnenediones; D012602:Scopolamine Derivatives; D009569:Nitric Oxide; C120481:ciclesonide; D000069447:Tiotropium Bromide