Severe Asthma

I once worked as a chemist and developed severe asthma as a result of an occupational exposure two years ago.  Since then I have had a very difficult clinical course.  I am taking predisone, advair, flovent, singulair, spriva, atrovent, and albuterol for my asthma.  The prednisone doses have always been high, and I have been unable to reduce the dose much below 30mg/day.  My pulmonologist tried Xolair, but I had an anaphylactic reaction following the second shot.  I have been dealing with a number of side effects from the medication including the development of two DVTs and a PE.  It has been 4 months since my PE, but my saturations have not returned.  They typically are 90-92 now (98-99 prior to the PE).  What could be the reason for the saturations not returning to normal? Also they found a spot of necrotic tissue in my right lung that was not there prior.  I have had one follow-up CT, and it has decreased in size.  I am scheduled for another CT in February. I have talked to National Jewish Hospital, but I have had all of the tests that they would perform (vocal cord dysfunction, sinus CT, etc.).  Is there anything else that could be suggested?

I know that there has been some success with methotrexate for reducing the steroid dependency, but I am a bit reluctant since I seem to be sensitive and often have a number of side effects. Is there any thing else that could be suggested?  I have read a few studies on i.v. Ig, but I do not know all of the details. Sorry for such a long post, but I am desperate for some relief.

[National Jewish Health]

Two possibilities come to mind, that might explain this combination of asthma and deep vein thrombosis (DVT).  These possibilities are both blood vascular diseases:  Churg-Strauss Syndrome and Hypereosinophilic Syndrome (PHS), the former rarely associated with DVT and pulmonary emboli (PE); the latter commonly associated with these conditions.  The necrotic tissue you describe could be the result of: 1) a pulmonary infarct, or 2) pulmonary vasculitis.  In the absence of gross pulmonary emboli, vasculitis could also account for your persistent oxygen desaturation.

Regarding your conversation with National Jewish Medical and Research Center, the value that a consultation would provide would not reside in additional testing, but rather in the expertise, both in immunology and respiratory disease, that the National Jewish physicians would bring to bear on your problem.

The alleged benefits of methotrexate have been repeatedly disproven by careful studies, but there are still anecdotal reports of periodic benefit.

As for intravenous immunoglobulin (IVIG), please note the following.  The efficacy of IVIG for the treatment of severe asthma in immunocompetent people is questionable.  The following abstract suggests that IVIG may be very useful in a sub-population of severe asthmatics with specific antibody deficiency.  Please note that not all IVIG preparations are the same.

You may want to share this information with your physicians.

Good luck

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