CRA19 18 ADMISSIONS WEREN’T ENOUGH! A CASE OF ACOS WITH PERIPHERAL BLOOD EOSINOPHILIA IN A RESTRICTED TREATMENT SETTING

Zulkifli.S1
Hospital Pakar Sultanah Fatimah, Muar

Introduction:

This case report describes the journey of a 62-year-old ex-smoker with a history of COPD, whose persistent respiratory symptoms and recurrent exacerbations led to the uncovering of an underlying ACOS with peripheral blood eosinophilia.

Case Report:

The patient, diagnosed with COPD GOLD E, presented with shortness of breath for 3 days. This was his 18th admission within a year, and he had been intubated on 3 previous occasions for severe exacerbations. Despite comprehensive treatment with Ultibro Breezehaler and Fluticasone, his symptoms remained uncontrolled.

Radiological investigations revealed hyperinflation and panlobular emphysema, while spirometry confirmed a moderate obstructive airway pattern. Notably, the patient's full blood counts showed persistent peripheral blood eosinophilia, with a peak level of 1,500 cells/μL. Further testing, including ANCA, C-ANCA, and total IgE, was unremarkable.

Upon further questioning, the patient revealed a history of childhood-onset asthma and a strong family history of asthma and eczema. He also reported diurnal variations in coughing, especially in the morning. Considering the patient's complex clinical presentation, the diagnosis of ACOS with peripheral blood eosinophilia was made.

In the absence of other treatment options in the district setting, the patient was started on oral corticosteroids, with a tapering dose of 15 mg of prednisolone daily. Since the initiation of oral corticosteroids, the patient has had no further admissions, and his Asthma Control Test (ACT) score has significantly improved, with a reduction in his reliance on reliever medication from 10-12 puffs per day to once every 1-2 days. 

Conclusion:

This case report underscores the challenges involved in diagnosing and managing ACOS, particularly in the context of a patient with a history of COPD and persistent peripheral blood eosinophilia which emphasises the need for heightened clinical awareness and a deep understanding of ACOS to provide optimal care for patients with overlapping respiratory disorders.