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Difficult-to-Control Asthma in a 49-Year-Old Man

Case Editor - Judd Flesch

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Emily Norder, MD

Clinical Instructor and Internal Medicine Resident

Department of Internal Medicine

The Ohio State University Medical Center

Columbus, Ohio

Maria Lucarelli, MD

Assistant Professor of Internal Medicine

Department of Internal Medicine

The Ohio State University Medical Center

Columbus, Ohio

Submit your comments to the author(s).


A 49-year-old white male presents to pulmonary clinic for evaluation of wheezing and dyspnea.  He has a history of asthma since childhood that has been well-controlled off medication until this past year.  He reports daily symptoms and almost nightly nocturnal awakenings due to shortness of breath, which is temporarily relieved with bronchodilators.  He has had several exacerbations in the past 6 months and required hospitalization for an episode 1 month ago.  He has been treated with tapering doses of oral prednisone for each exacerbation and reports his symptoms worsen each time he completes a steroid taper. 

His past medical history is also significant for perennial allergies and chronic sinusitis requiring three surgeries.  His current medications include: fluticasone/salmeterol 500 μg/50 μg twice daily, zileuton 1200 mg twice daily, prednisone 10 mg daily, montelukast 10mg once daily and albuterol on an as-needed basis which he is currently using four times daily.  He was started on omalizumab 300 mg/month, 4 months ago without significant improvement.  He is a lifelong nonsmoker and denies any illicit drug use.

Physical Exam

On physical examination, vital signs are normal with Spo2 on room air of 95%.  His head and neck exam is benign.  His pulmonary exam is significant for diffuse expiratory wheezes with prolonged expiratory phase.  Cardiac exam reveals regular rate and rhythm with no murmurs, rubs or gallops. There is no clubbing or cyanosis in his extremities.


Pulmonary Function Tests
  • Spirometry: FEV1- 2.12 L (58%); FVC- 3.63 L (77%); FEV1/FVC- 58.4%; post-bronchodilator studies FEV1- 2.38 L (increase of 12%); FVC- 3.98 L (increase of 10%)


Figure 1: Posterior-anterior (PA) chest radiograph was within normal limits.

Figure 2: Axial view of high-resolution chest CT using lung windows showing mild central bronchiectasis.

Question 1

Which of the following is important in the further work-up of this patient?


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