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To the Editor.
Akritids and coworkers (February 2003)1 reported a 56-year-old woman who presented with fever and productive cough of 2 weeks in duration because of achalasia. They comprehensively assessed the signs and symptoms, and the patient examination was almost perfect; achalasia associated with aspiration pneumonia was diagnosed. Although the symptoms could be explained by achalasia associated with aspiration pneumonia, they may have missed the diagnosis.
We believe that the case should be diagnosed as diffuse aspiration bronchiolitis (DAB) due to achalasia. DAB is a new term that we promised to define a clinical entity that is characterized by a chronic inflammation of bronchioles caused by recurrent aspiration of foreign bodies.2 Recurrent aspiration causes cough and waxing and waning pulmonary lesions.2 Although DAB is originally recognized as a disease in the elderly, our survey revealed that DAB occurred in young patients with the same clinical manifestations as those observed in the elderly.3-5 In younger patients, dysphagia due to achalasia and gastroesophageal reflux disease (GERD) with associated recurrent aspiration are major risks for development of DAB.3-5 DAB caused by achalasia was diagnosed in three patients aged 11, 12, and 56 years, respectively.3-5
Dysphagia and GERD are considerably associated with swallowing disorders and aspiration.6-11 Both the impaired lower esophageal sphincter and the depressed upper airway reflex contribute dependently or independently to recurrent lung infiltrates, resulting in the manifestation of DAB.
In the current case, the patient had a long history of a chronic dry cough that was worse at night, and had dysphagia for 15 years for solids and liquids, with substernal chest discomfort and pain that was unrelated to meals or exercise. When aspiration pneumonia, as the authors diagnosed, is a primary disorder, the symptoms are of acute onset and severe. However, the symptoms are generally insidious and chronic. Recurrent aspiration causes cough and waxing and waning pulmonary lesions, but does not always cause aspiration pneumonia. The history and the manifestation of symptoms are quite similar to DAB in the elderly.
It may be interesting to know whether the lung pathology revealed chronic mural inflammation with multinucleated histiocytes, ie, foreign body reaction, in bronchioles, which is...