Successful treatment of allergic bronchopulmonary aspergillosis with benralizumab after no response to omalizumab

Author:

David González De Olano, Lorena Bernal-Rubio, Pía De-Calzada-Bustingorri, Gonzalo De-Los-Santos-Granados, Carlos Almonacid-Sánchez, Belén De-La-Hoz-Caballer

Author address:

Spain

Full conference title:

European Academy of Allergy and Clinical Immunology Congress 2020

Abstract:

Case report

Introduction: Allergic Bronchopulmonary Aspergillosis (ABPA) is an allergic reaction to Aspergillus fumigatus. It mainly affects people with asthma. The most typical manifestations include chest tightness, dyspnea, elevated IgE levels, eosinophilia and transient pulmonary infiltrates with moderate fever and coughing up brown sputum plugs. The key to treatment is oral corticosteroids (OC). In recent years, cases of good clinical evolution after concomitant administration of omalizumab have been described and, more recently, the use of anti-IL 5 monoclonal antibodies have also has also proven to be effective.
Material and methods: A 67-year-old male with a history of intrinsic asthma followed since 1995 (regular FEV1 3180ml -90) was referred to our office in 2018 for clinical worsening. A complete allergologic study was performed including CBC, total and specific IgE determinations, respiratory function tests and chest CT.
Results: FEV1 was 860ml – 29%-. Skin prick test to Aspergillus f. were positive and the blood tests revealed a total IgE of 641kU/L, sIgE to Aspergillus f. of 8.41kU/L, IgG to Aspergillus f. of 93 U/L and 590 eos/µl. CT scan showed cylindrical-varicoid bronchiectasis (right middle lobe and lingula), mucus plugs and linear and micronodular peribronchial parenchymal opacities in lower and upper lobes. A diagnosis of ABPA was reached. The patient started on oral prednisone (0.5mg/kg) and itraconazole 200mg/12. Treatment with OC was guided according to the guidelines and withdrawal was attempted after 6 months. As it is not possible to go below 7.5 mg/day due to bad clinical situation (FEV1 1970 ml -62%-), omalizumab was added (300mg each 4 weeks). After 6 months, omalizumab was switched to benralizumab since no improvent was detected and there was no possibility of cutting back on medication. After the first dose FEV1 increased up to 2630ml – 83%- with no eosinophils detected. After 5 monts of treatment with benralizumab FEV1 remains within the normal range (2830ml – 90%-) and OC have been withdrawn.
Conclusions: ABPA is common in patients with asthma that has been progressing for years. Monoclonal antibodies can be used in ABPA as an adjuvant to OC treatment. We present a case of a patient with ABPA who improved with benralizumab after not achieving clinical modification with omalizumab. Physicians must assess the different immune mechanisms involved in the disease and take into account all the therapeutic options.

Abstract Number: 1448

Conference Year: 2020

Link Conference abstract: 

EAACI 2020

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