In a 33‑year‑old male with asthma on budesonide/formoterol (Symbicort) four times daily, presenting with worsening productive yellow cough, high fever, tachycardia, left temple tenderness, and left boggy nasal turbinate after a recent emergency department visit for asthma exacerbation, what are the most likely diagnoses and next management steps?

Likely Diagnoses

This patient most likely has acute bacterial sinusitis complicating his asthma exacerbation, with possible concurrent viral upper respiratory infection. The constellation of left temple tenderness, boggy nasal turbinate, purulent nasal discharge matching sputum character, high fever peaking at night, and failure to respond to escalated asthma therapy over 2 weeks strongly suggests bacterial sinusitis as the primary driver of his persistent symptoms 1.

Primary Diagnostic Considerations

1. Acute Bacterial Sinusitis (Most Likely)

• Left temple tenderness on palpation is a classic sign of frontal or maxillary sinusitis, indicating inflammation of the paranasal sinuses 1.
• Boggy, non-erythematous left nasal turbinate indicates chronic mucosal inflammation and edema consistent with sinusitis 1.
• Purulent nasal discharge "resembling the expectorated sputum" (thick yellow tinges) indicates post-nasal drip from infected sinuses draining into the airways, which explains both the productive cough and the matching character of nasal and bronchial secretions 1.
• High fever (39.5°C) with nocturnal predominance is characteristic of bacterial infection rather than viral or allergic processes 2.
• Failure to improve despite quadrupling inhaled corticosteroid/LABA therapy over 2 weeks suggests an infectious trigger that requires antimicrobial treatment rather than bronchodilator escalation alone 1, 2.

2. Viral-Triggered Asthma Exacerbation (Contributing Factor)

• Rhinoviruses and other respiratory viruses are the most common triggers of asthma exacerbations in adults, causing 60-80% of acute episodes 3, 4.
• The 2-week prodrome of worsening cough followed by fever suggests an initial viral upper respiratory infection that has now been complicated by secondary bacterial sinusitis 5, 4.
• Viral infections cause release of pro-inflammatory cytokines and recruit neutrophils, lymphocytes, and eosinophils, perpetuating airway inflammation even after the acute viral phase 3.

3. Inadequately Controlled Asthma with Infectious Trigger

• Recent ED visit 2 weeks ago indicates this patient has "exacerbation-prone" asthma, a phenotype associated with recurrent acute episodes 3.
• Tachycardia (118 bpm) indicates ongoing bronchospasm and increased work of breathing, though beta-agonist therapy will further elevate heart rate 1, 6.
• Preference for supine position is unusual in acute asthma (most patients prefer upright positioning) and may indicate fatigue, systemic illness from infection, or sinus pressure relief 1.

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Immediate Next Steps

1. Objective Severity Assessment (First 5 Minutes)

• Measure peak expiratory flow (PEF) or FEV₁ immediately to objectively classify exacerbation severity; subjective assessment alone frequently underestimates severity and is a leading preventable cause of asthma mortality 1, 6, 7.
• Obtain pulse oximetry and maintain SpO₂ >90% (>95% if cardiac disease) with supplemental oxygen via nasal cannula or mask 6.
• Assess for severe exacerbation features: inability to complete sentences in one breath, respiratory rate >25/min, heart rate >110/min (already present at 118 bpm), PEF <50% predicted 1, 6, 7.
• Assess for life-threatening features: PEF <33% predicted, silent chest, cyanosis, altered mental status, normal or elevated PaCO₂ ≥42 mmHg 1, 6, 7.

2. Immediate Pharmacologic Treatment (Within First 15 Minutes)

• Administer high-dose nebulized albuterol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer immediately, repeating every 20 minutes for three doses (at 0,20, and 40 minutes) 1, 6, 8.
• Give oral prednisone 40-60 mg immediately (single dose today, then continue daily for 5-10 days with no taper needed) 1, 6, 8.
• Add ipratropium bromide 0.5 mg to each of the first three nebulizations for moderate-to-severe exacerbations; the combination reduces hospitalizations 1, 6.
• Do NOT delay corticosteroids while "trying bronchodilators first"—both must be given concurrently as steroids require 6-12 hours to manifest clinical benefit 1, 6.

3. Diagnostic Imaging for Sinusitis Confirmation

• Obtain sinus imaging (CT scan preferred over plain films) to document acute or chronic sinusitis given the clinical triad of temple tenderness, boggy turbinate, and purulent discharge 1.
• Air-fluid levels on imaging are diagnostic of acute bacterial sinusitis and mandate antibiotic therapy 1.
• Mucosal thickening is less specific but in the context of chronic cough unresponsive to asthma treatment should be treated presumptively as sinusitis 1.
• Obtain chest X-ray to exclude pneumonia, pneumothorax, or pulmonary edema, especially given the 2-week duration and fever 1, 6.

4. Antimicrobial Therapy for Bacterial Sinusitis

• Initiate empiric antibiotic therapy immediately if sinus imaging shows air-fluid levels or if clinical suspicion is high (temple tenderness + purulent discharge + fever) 1, 2.
• First-line antibiotics: amoxicillin 500 mg three times daily or amoxicillin-clavulanate 875/125 mg twice daily for 10-14 days 1, 2.
• Alternative agents: trimethoprim-sulfamethoxazole or doxycycline if penicillin allergy 2.
• Most acute bacterial exacerbations in asthma/bronchitis are caused by Haemophilus influenzae, Streptococcus pneumoniae, or Moraxella catarrhalis 2.
• Continue antibiotics for minimum 10-14 days to increase the infection-free interval until the next bacterial exacerbation 2.

5. Reassessment Protocol (15-30 Minutes After First Bronchodilator)

• Remeasure PEF 15-30 minutes after the first nebulizer dose to guide disposition 1, 6.
• Good response (PEF >75% predicted): Continue outpatient management with oral prednisone, antibiotics for sinusitis, and step-up asthma controller therapy 1, 6.
• Incomplete response (PEF 50-75% predicted): Maintain nebulized albuterol every 4 hours, continue oral prednisone and antibiotics, and strongly consider hospital admission if severe features persist 1, 6.
• Poor response (PEF <50% predicted or persistent severe features): Increase nebulizer frequency to every 15-30 minutes, continue ipratropium every 4-6 hours, and arrange immediate hospital admission 1, 6.

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Additional Management Considerations

Adjunctive Therapies for Severe/Refractory Cases

• Intravenous magnesium sulfate 2 g over 20 minutes should be given if life-threatening features are present or if PEF remains <40% after 1 hour of intensive treatment 1, 6.
• Consider continuous albuterol nebulization (10-15 mg/hour) for patients failing intermittent therapy 6.
• Intravenous aminophylline 250 mg over 20 minutes may be used for refractory severe asthma, but never give a bolus to patients already on oral theophylline due to toxicity risk 1, 6.

Hospital Admission Criteria

• Immediate admission required for any life-threatening feature (PEF <33%, silent chest, altered mental status, PaCO₂ ≥42 mmHg) 1, 6, 7.
• Admit if severe attack features persist after initial treatment (inability to speak sentences, RR >25/min, HR >110/min, PEF <50% after 1-2 hours) 1, 6.
• Lower threshold for admission given afternoon/evening presentation, recent ED visit 2 weeks ago, and "exacerbation-prone" phenotype 1, 3.

Critical Pitfalls to Avoid

• Never administer sedatives during acute asthma—they are absolutely contraindicated and potentially fatal 1, 6.
• Do not assume antibiotics are unnecessary in asthma exacerbations; while typical bacterial pathogens don't initiate exacerbations, bacterial sinusitis is a well-recognized comorbidity requiring treatment 1, 2, 5.
• Do not rely solely on clinical impression—objective PEF measurement is mandatory to avoid underestimating severity 1, 6, 7.
• Do not delay systemic corticosteroids—they must be given immediately, not after "trying bronchodilators first" 1, 6.

Follow-Up Planning

• Arrange primary care follow-up within 1 week to reassess asthma control and sinusitis resolution 1, 6, 8.
• Schedule respiratory specialist follow-up within 4 weeks given recent hospitalization and recurrent exacerbations 1, 6.
• Verify inhaler technique and provide written asthma action plan with PEF zones before discharge 1, 6.
• Consider allergy testing and environmental evaluation if sinusitis is recurrent or refractory to medical therapy 1.
• Measure serum immunoglobulin levels if sinusitis fails to respond to appropriate antibiotic therapy, to exclude acquired hypogammaglobulinemia 1.