Abstract
Patients on immunosuppressant agents, including oral corticosteroids, are susceptible to fungal colonization despite being otherwise immunologically intact. This case report highlights a state-of-the-art biological modifier therapy for the complex care of a patient with refractory occupational asthma, allergic rhinitis, and mixed fungal colonization.A dyspneic 38-year-old male janitor with steroid-dependent occupational asthma refractory to omalizumab therapy was colonized with Candida and Alternaria following a promotion to a managerial position in a moldy office. He was treated with itraconazole and systemic steroids. Pulmonary workup revealed moderate obstructive ventilatory defect, peripheral airway hyperresponsiveness, and eosinophilic airway inflammation. Three additional biological modifiers (reslizumab, benralizumab, and dupilumab) were administered to this patient. His asthma was ultimately controlled with reslizumab and dupilumab. Fractional exhaled nitric oxide (FeNO) normalized after dupilumab monotherapy, enabling the patient to taper off chronic prednisone therapy.Various occupational exposures are crucial epidemiologic factors related to infection and go hand-in-glove with long-term prednisone treatment towards increasing susceptibility to fungal colonization. Steroid-sparing anti-interleukin-5 (IL-5) agents and dupilumab should be considered as alternative treatment options for patients, such as ours, with eosinophilic, prednisone-dependent asthma refractory to omalizumab therapy.
Highlights
Occupational exposure to cleaning and sterilizing agents is a known cause of occupational asthma
A history of atopy, presence of high serum immunoglobulin E (IgE), poorlycontrolled asthma, and occupational exposures are all characteristics of sensitizer-induced asthma, which is an occupational asthma subtype wherein aerosolized irritants promote eosinophilic inflammation [1,2,3,4]
Janitors are often exposed to aerosolized dust mite and mold antigens, such as Dermatophagoides pteronyssinus and farinae, as well as Penicillium and Aspergillus spp., which have been implicated in occupational asthma [7,8,9]
Summary
Occupational exposure to cleaning and sterilizing agents is a known cause of occupational asthma. Percutaneous skin prick testing was significant for Dermatophagoides farinae and pteronyssinus, and his serum IgE had been found to be 2,000 IU/ml during a previous hospitalization He had worked for many years as a janitor in professional healthcare settings, with occupational exposure to fumes from industrial cleaning agents. One year after initiating treatment at our office, the patient presented with green nasal discharge bilaterally and worsening dyspnea He was afebrile, and the physical exam revealed constant anterior and posterior rhonchi with wheezing throughout all lung fields. Despite improvement in respiratory symptoms, antifungal therapy was discontinued after one month due to itraconazole-induced personality changes At this time, repeat sputum culture was found to be negative for fungal growth. Test name Immunoglobulin G (IgG), serum Immunoglobulin G, subclass 1 Immunoglobulin G, subclass 2 Immunoglobulin M (IgM) Helper (CD4)/suppressor (CD8) ratio
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