allergic bronchopulmonary aspergillosis ( abpa ) is a dual type i and iii hypersensitivity response to aspergillus antigens and is typically associated with patients with asthma and occasionally with cystic fibrosis . patients with current or previous tuberculosis may develop aspergillus - related lung disease including aspergilloma and chronic pulmonary necrotizing aspergillosis cpna . however , abpa without asthma has so far not been known to complicate previous pulmonary tuberculosis though typical abpa may occur concurrently with active tuberculosis or follow it . a 30-year - old lady , non - smoker and housewife , presented with complaints of progressive exertional breathlessness without wheezing , and productive cough that was occasionally blood - streaked , with three to four febrile episodes every year . two years ago , she was diagnosed to have sputum direct - smear acid - fast bacilli ( afb)-positive pulmonary tuberculosis , received anti - tubercular treatment for six months and was declared cured . however , breathlessness and cough persisted . examination revealed dullness on percussion and coarse inspiratory crepts bilaterally in the infraclavicular areas with bronchial breath sounds on the left side . she had a hemoglobin of 8.8 g / dl and a total leucocyte count of 10500/mm with 75% neutrophils and 5% eosinophils . the plain chest radiograph revealed extensive bilateral fibrosis , more on the left side with a right upper zone cavity . sputum cultures for pyogenic organisms and direct - smear examination for afb ( three consecutive morning samples ) were negative . lung function tests showed a restrictive ventilatory defect : forced vital capacity ( fvc ) , 1.25 l ( 37% predicted ) ; forced expiratory volume in 1 s ( fev1 ) 0.96 l ( 32% predicted ) ; fev1/fvc ratio , 77% ; total lung capacity , 1.72 l ( 37% predicted ) . plain chest radiograph ( pa view ) showing extensive bilateral fibrosis , more on the left side with a right upper zone cavity . a few cystic shadows were seen in both lungs a high - resolution computed tomogram ( hrct ) revealed bilateral upper lobe fibrocavitary lesions , more on the left side , with central bronchiectasis as well as middle - lobe bronchiectasis [ figures 2 and 3 ] . a diagnosis of post - tubercular fibrocavitary sequelae was made . high - resolution computed tomogram of the chest ( lung window ) showing bilateral upper lobe fibrocavitary lesions , more on the left side , with central bronchiectasis high - resolution computed tomogram of the chest ( lung window ) showing middle - lobe and bilateral central bronchiectasis the presence of central bronchiectasis , a radiological sign characteristically associated with abpa , prompted further investigations which were as follows : skin prick tests for type 1 hypersensitivity reaction against aspergillus fumigatus and aspergillus niger positive ; serum total immunoglobulin e ige elevated ( 8512 iu / ml ) , serum precipitins and specific immunoglobulin g ( igg ) against aspergillus fumigatus , positive , elevated titers of specific ige against aspergillus fumigatus ( 48.7 kua / l ) ; sputum for fungus on direct microscopy showed branching septate hyphae ; culture negative for fungal growth . thus , the patient was advised oral prednisolone , 30 mg daily that was tapered over five to six months as the patient improved . post treatment , the serum ige levels had decreased to 2416 iu / ml and serum precipitins against aspergillus fumigatus became negative . during the next one year , the patient had a relapse of symptoms twice with elevation of serum ige levels and serum precipitins against aspergillus fumigatus turning positive . two consecutive sputum cultures this time also revealed growth of aspergillus fumigatus . on both occasions , the patient responded to reinstitution of corticosteroids with reduced serum ige levels and serum precipitins became negative . the diagnosis of abpa is based on hematological , radiological and immunological criteria along with presence of asthma , and occasionally , cystic fibrosis . however , abpa occurring without asthma is very uncommon and such instances have been documented as case reports.[24 ] while an aspergilloma is well known to complicate cavities resulting from a previous tuberculous disease , aspergillus sensitization in patients with prior tuberculosis remains largely unexplored . a literature search yielded only one case reporting abpa in a patient with post - tubercular sequelae in whom wheezing and airways obstruction were present suggesting asthma . our patient , however , had differences as there was no history suggestive of asthma and lung function tests showed a restrictive pattern . all the required diagnostic criteria for abpa were satisfied except asthma . the clinical and immunological response it has been suggested that the cd4+/th 1 type of immune response in tuberculosis may protect against the development of asthma that is associated with a th 2 type of response . mycobacteria culture supernatants have been shown to effectively prevent the development of asthma associated with altered th1/th2 cytokines in sensitized mice . therefore , it is possible that protection against atopic conditions may wane and allergic conditions may manifest after tuberculosis is treated . nevertheless , clinical experience shows that occurrence of wheezing and airways obstruction after treatment of tuberculosis is common and is attributed to endobronchial inflammation , scarring and mechanical distortion of the tracheobronchial tree . interestingly , one study reported that the majority of patients with post - tubercular wheezing actually had confirmed bronchial asthma emerging within three years of stopping anti - tuberculosis treatment and required prolonged corticosteroid administration . the remarkable feature of our patient was the absence of asthma while all other diagnostic criteria for abpa were satisfied . abpa complicating previously treated tuberculosis and occurring without asthma has never been reported earlier . as aspergillus colonization in the airways and healed cavities is common in lungs with previously treated tuberculosis ; sensitization may develop if the subject is atopic . although our patient did not have asthma , she had atopy as shown by a history of allergic rhinitis and raised total ige . the case highlights the curious link between tuberculosis and atopy and also suggests that presence of atopy without manifest asthma is sufficient for abpa to develop . patients with post - tubercular cough and dyspnoea should be investigated for abpa if they are atopic .
allergic bronchopulmonary aspergillosis ( abpa ) is typically associated with asthma . 
 presence of asthma is one of the minimal essential diagnostic criteria for abpa . 
 rarely , abpa has been described in association with other diseases without asthma . 
 it has so far not been known to complicate pulmonary tuberculosis . 
 we report one such case in a young lady where all other diagnostic criteria were fulfilled . 
 the patient responded to corticosteroids and then had acute exacerbations of abpa twice , each time requiring an increased dosage of corticosteroids as well as itraconazole and responded favorably .