Asthma-COPD Overlap Syndrome Developed in Herbal Tea Processor with Sensitizer-Induced Occupational Asthma – A Case Report

Asthma-COPD overlap syndrome (ACOS), a clinical syndrome common in routine practice, is still not fully defi ned entity characterized by features of both asthma and chronic obstructive pulmonary disease (COPD). In the present article a case with clinical syndrome of chronic airways disease sharing characteristics of asthma and COPD is described. In a 57-year old man working in herbal tea manufacture the diagnosis of sensitizer-induced occupational asthma (OA) was established at the age of 45 by recommended diagnostic work-up. After the diagnosis was established he was removed from the offending workplace exposure, the pharmacological treatment with inhaled corticosteroid was started and he was advised to quit smoking. He stopped use of the recommended medications after about two years and did not quit smoking. We saw the patient about 10 years after his last visit and he reported cough with sputum production and exertional dyspnea in the past one to two years. The spirometric fi ndings indicated persistent airfl ow obstruction with positive response to bronchodilator. The features of COPD in the previously diagnosed asthmatic suggested overlap between two chronic airways diseases, i.e. the diagnosis of ACOS. Pharmacological treatment with combined therapy (inhaled corticosteroid and long-acting 2-agonist) was started and he was advised to attend the programme for smoking cessation. Case Report Asthma-COPD Overlap Syndrome Developed in Herbal Tea Processor with Sensitizer-Induced Occupational Asthma – A Case Report Jordan Minov1*, Jovanka Karadzinska-Bislimovska1, Kristin Vasilevska2, Saso Stoleski1, Dragan Mijakoski1 and Aneta Atanasovska1 1Institute for Occupational Health of R. Macedonia, Skopje, WHO Collaborating Center, Macedonia 2Institute of Epidemiology and Biostatistics, Skopje, R. Macedonia Dates: Received: 17 February, 2017; Accepted: 22 February, 2017; Published: 23 February, 2017 *Corresponding author: Jordan B Minov, MD, PhD, Institute for Occupational Health of R. Macedonia, WHO Collaborating Center and GA2LEN, Collaborating Center, II Makedonska Brigada 43, 1000 Skopje, R. Macedonia, Tel: + 389 2 2461 387; Fax: + 389 2 2621 428; E-mail:

in COPD patients. In contrast, from an asthma perspective, the identifi cation of characteristics of COPD is not so clear, especially in never smokers with asthma. Namely, an asthma patient cannot be diagnosed having ACOS only based on the incomplete reversibility of airfl ow obstruction, i.e. on the value of post-bronchodilator ratio between forced expiratory volume in 1 second and forced vital capacity (FEV 1 /FVC) less than 0.7. In the cases of never-smoking patients, they should be classifi ed as having severe or not completely reversible asthma, while in the cases of daily smokers or ex-smokers the diagnosis of ACOS is more reliable [1][2][3].
There is evidence that patients with ACOS experience frequent exacerbations, have poor quality of life, a more rapid decline in lung function, and high mortality than asthma or COPD alone [4][5][6]. The proportion of patients with both asthma and COPD is unclear and infl uenced by the used inclusion criteria. However, according to the results of several studies, prevalence rate varies between 15 and 55% [7,8].
As it is mentioned above, ACOS is still controversial The aim of this case report is to present a history of smoking patient with sensitizer-induced asthma due to occupational exposure in herbal tea manufacture in whom a persistent airfl ow limitation was developed over time.

Case Report
The patient is a 57-year old man in whom sensitizerinduced asthma was diagnosed at the age of 45. At the time of diagnosis he worked as herbal tea manufacturer for 10 years.
The patient had a positive family history of asthma, he was active smoker for about 25 years, smoking 20-25 cigarettes per day. The patient suffered from cough with shortness of breath and wheezing that was more pronounced during and after work shifts with symptom-free periods during weekends and holidays. The symptoms occurred approximately two years after he has started working as herbal tea processor.
Before referring to the Institute, he was diagnosed as chronic bronchitis and treated with antibiotics, inhaled short-acting removed to the workplace in which he was not exposed to herbal tea dust (guardian in the administrative unit), pharmacological treatment was started (regular use of inhaled corticosteoid as monotherapy and short-acting  2 -agonist as needed) and he was advised to quit smoking. Over the fi rst two years after the diagnosis of sensitizer-induced OA was established the patient underwent control checkups reporting regular use of recommended controller and improvement of the symptoms but he did not quit smoking. In addition, spirometric fi ndings during this period were within their referrent values [9,10].
The patient was again reffered to the Institute approximately 10 years after the last control checkup. As he said, he felt good and stopped use of the controller for 8-9 years. In addition, he still worked as guardian in the administrative unit of the tea manufacture and did not quit smoking. In the last one to two years he experienced cough with sputum production and exertional dyspnea the expression of which was variable.  Table 1.
The chest X-ray showed signs of hyperinfl ation, and the high resolution CT scan (HRCT) signs of air trapping and increased bronchial wall thickness (diagnosis of bronchiectasis was ruled out). The patient showed some features of both asthma and COPD suggesting the diagnosis of ACOS according to the actual recommendations. Pharmacological treatment with moderate dose of inhaled corticosteroid and long-acting  2 -agonist was initiated. In addition, he was reffered to an organized programme for smoking cessation. In the present case report we described the diagnostic work-up and initial treatment option in an elderly patient with a smoking history of over 30 years in whom the diagnosis of sensitizer-induced OA due to herbal tea dust exposure was established 10 years before the actual diagnosis. After the diagnosis of sensitizer-induced OA was established, the patient was removed to another workplace free of herbal tea dust exposure, the monotherapy with inhaled corticosteroid was started and he was advised to quit smoking. The patient was re-assessed more than 10 years after initial diagnosis. He reported that as he felt good, he stopped use of recommended therapy many years ago, but he still smoked. The diagnostic work-up followed the step-wise approach recommended by the GINA/GOLD consensusbased document which includes fi ve steps: identifi cation of chronic airways disease; syndromic diagnosis of asthma, COPD or ACOS; spirometry; commencing initial therapy and specialized investigations to exclude alternative diagnosis. OA is still a fi eld of many controversies and uncertainties [15,16].

Discussion
Despite to our knowledge in the existing evidence a case with ACOS developed on the basis of sensitizer-induced OA is not reported, we considered the diagnosis of ACOS as the patient had similar number of features of both asthma and COPD [1,17].
The development of COPD in atopic and asthmatic patient could be explained by a long history of smoking. As the results of the assessment suggested ACOS, the initial treatment included an inhaled corticosteroid in a moderate dose and a long-acting  2agonist [1,13]. In addition, the treatment also included smoking cessation which should be realized by attending the specialized programme [1,8].

Conclusion
In