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.