Successful management of recurrent allergic bronchopulmonary aspergillosis after changing from mepolizumab to dupilumab: A case report

• DOI: 10.1016/j.rmcr.2022.101723
• Publication Date: 2022-08-17T10:03:56Z
• Authors: Yoshiro Kai; Masanori Yoshikawa; Masayuki Matsuda; Kentaro Suzuki; Masato Takano; Kazuya Tanimura; Nobuhiro Fujioka; Yukio Fujita; Shigeo Muro
• Keywords: Diseases of the respiratory system; 03 medical and health sciences; 0302 clinical medicine; RC705-779; Prednisolone; IL-13; Allergic bronchopulmonary aspergillosis; IL-4; Case Report; Dupilumab; Mepolizumab

An 81-year-old woman presented to our hospital due to an abnormal shadow on a chest X-ray and a 4-week-old persistent cough. Laboratory examination revealed increased serum eosinophils and immunoglobulin E. The Asthma Control Test (ACT) score and forced expiratory volume in 1 sec indicated airway obstruction. Chest computed tomography (CT) revealed mucoid impaction in the dilated left-lingular lobar bronchus. She was diagnosed with bronchial asthma and treated with a high-dose inhaled corticosteroid/long-acting β2 agonist. Two months later, her mucoid impaction in the CT image worsened; moreover, bronchoscopy revealed the white mucus plug with Charcot–Leyden crystals and filamentous fungi. The patient was diagnosed with Allergic bronchopulmonary aspergillosis (ABPA) and treatment with 30 mg/day prednisolone was started. Both the blood eosinophil count and the chest image improved almost substantially, and the steroid was discontinued after a year. Sixteen months after cessation of prednisolone treatment, peripheral eosinophilia and mucoid impaction in the left B3b recurred. For the treatment of bronchial asthma and recurrent ABPA, administration of mepolizumab was initiated. Subsequently, although her peripheral eosinophils count decreased, chest CT showed expansion of the mucoid impaction and IgE increased despite mepolizumab treatment. Alternative subcutaneous injection therapy with dupilumab improved chest image, serum IgE level, and her ACT score. After changing from mepolizumab to dupilumab, her ABPA, asthma, and pulmonary function improved remarkably. This case illustrates the potential utility of dupilumab for ABPA without re-administration of oral prednisolone. Additional research is needed to identify an effective therapy for ABPA with asthma.