Abstract
BackgroundAllergic bronchopulmonary aspergillosis (ABPA) is a severe hypersensitivity reaction to aspergillus species colonizing the airways of patients with asthma or cystic fibrosis. Biologics including anti-IgE and anti-IL5 antibodies have strongly changed the treatment of severe asthmatics and have partly been reported to be effective in the treatment of ABPA. Recently, dupilumab, an anti-IL4-Rα antibody which inhibits signaling by the Th2-cytokines IL4 and IL13, has been approved for the treatment of severe asthma.Case presentationHere, we report the case of a 49-year-old woman with severe asthma and ABPA, who was uncontrolled despite maximum inhalative therapy, anti-IL5-Rα antibody and continuous oral steroid therapy. Moreover, trials of itraconazole as well as omalizumab showed insufficient efficacy. Lung function revealed peripheral obstruction. FeNO and IgE were increased, eosinophils were suppressed under treatment while marked increases had been documented previously. Switching to dupilumab led to a complete resolution of pulmonary symptoms, resolution of exacerbations and complete withdrawal of oral steroids. A drastic improvement in lung function was noted, with an increase in FEV1 of almost 1 l. FeNO was normalized and IgE strongly reduced.ConclusionOur case highlights that a patient may exhibit differential treatment responses to the currently available asthma biologics and suggests switching treatment if outcome is insufficient. A potential role for dupilumab in the treatment of ABPA warrants future studies.
Highlights
Allergic bronchopulmonary aspergillosis (ABPA) is a severe hypersensitivity reaction to aspergillus species colonizing the airways of patients with asthma or cystic fibrosis
Our case highlights that a patient may exhibit differential treatment responses to the currently available asthma biologics and suggests switching treatment if outcome is insufficient
It should be noted that the sequence in which the different biologics were applied here was mainly due to availability and licensing status of the drugs: dupilumab had only just become licensed for severe asthma when therapy was started in this patient
Summary
This case report suggests that biological treatment should be switched to a drug with a different target, if treatment outcome under the previous biologic was insufficient. Patient perspective “After nearly 50 years of breathlessness, therapy with dupilumab changed my life from one day to the : to breathe without resistance is really a new quality of life! I am doing at minimum one hour of sport each day (bicycling, rowing) since 35 years, even when this was hard to practice. Second: I lost, after starting with dupilumab and stopping cortisone, 17 kg of weight within three months with a fasting cure. This is giving me a reliable and hopeful perspective for my future.”
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