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The efficacy of mepolizumab as an alternative to glucocorticoids for treating idiopathic chronic eosinophilic pneumonia (ICEP) has been reported. However, various questions remain unanswered, such as the most appropriate dose and dosage interval of mepolizumab for ICEP, how long efficacy is maintained, how long administration should be continued, and whether and when discontinuation can be considered. We present herein three cases of refractory ICEP treated with mepolizumab at a dose of 100 mg every 4 or 8 weeks. No recurrences were observed after 77 months of treatment in Case 1 and after 45 months in Case 2. Case 3 was treated with mepolizumab for 33 months, but ICEP relapsed 42 months after discontinuation of mepolizumab. In conclusion, mepolizumab for refractory ICEP should be continued for as long as possible, considering disease status, glucocorticoid-related adverse events, and the financial situation of the patient.

A 67-year-old woman with a history of poorly controlled asthma was admitted to our hospital with a persistent cough and abnormal chest radiographic findings. Her diagnosis was allergic bronchopulmonary aspergillosis (ABPA). Following treatment with mepolizumab, her symptoms and imaging findings improved initially. However, after approximately 2 years, the patient experienced a recurrent cough with elevated non-specific immunoglobulin E levels and worsening chest imaging findings, thereby changing her diagnosis to recurrent ABPA. Mepolizumab was substituted with dupilumab, and her subjective symptoms and imaging findings improved. Our findings suggest that dupilumab may be effective in ABPA cases following the failure of another antibody therapy.

Severe Asthma (SA) is characterized by inadequate disease control despite maximal inhalation therapy. In November 2021, a 68-years old female patient presented at our facility referring a worsening in her asthma-related symptoms and a high exacerbations rate. She reported a liver transplantation in 2015 and was in treatment with tacrolimus. We started treatment with Mepolizumab 100 mg once every 28 days and monitored her lung function as well as her lymphocytes subsets. After one year follow-up, the patient had a substantial improvement in lung function, exacerbation rate, daily OCS intake dose and no variation in the blood concentration of tacrolimus.

Allergic bronchopulmonary aspergillosis (ABPA) is an allergic reaction caused by the fungus Aspergillus, and it is often treated with steroids or antifungal agents. However, long-term use of these medications can lead to infections and drug interactions. We present the case of a 71-year-old woman with ABPA who was diagnosed with hepatitis B and active hepatitis C, and sputum analysis revealed the presence of bacteria. Oral steroids were initially administered, but the patient was switched to mepolizumab because of numerous infectious complications. The early introduction of mepolizumab is effective in patients with ABPA complicated by infectious diseases.

A 26-year-old female with steroid dependent eosinophilic asthma and nasal polyps who had successfully been treated with mepolizumab for 17 consecutive months with complete steroid withdrawal and symptoms control, stopped biologic treatment due to pregnancy efforts. Mepolizumab discontinuation resulted in frequent exacerbations and daily symptoms despite high dose ICS/LABA and re-initiation of oral steroids. Mepolizumab was initiated again, followed by improvement of asthma control and gradual withdrawal of steroids within 2 months. The patient became pregnant during the fourth month of mepolizumab re-initiation. The patient presented two asthma exacerbations during pregnancy treated with short course (3 days) oral steroids and delivery was uneventful (female, Apgar 9, weight 2750 g, length 59 cm) in week 40 by caesarean section.

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.

We report the case of a 50-year-old man with allergic bronchopulmonary mycosis (ABPM) complicated with bilateral septic arthritis of the knees caused by Methicillin-resistant Staphylococcus aureus (MRSA). He had a background of bronchial asthma and end-stage renal failure on maintenance dialysis. He was treated with 30 mg/day of prednisolone for 14 days for ABPM. He developed bilateral septic arthritis of the knees, caused by MRSA during prednisolone treatment. He underwent bilateral arthroscopic washout with a 2-week course of intra-articular arbekacin, concomitantly treated with a 6-week course of intravenous teicoplanin and oral rifampicin, subsequently followed by oral linezolid treatment. However, he suffered exacerbation of ABPM during treatment of septic arthritis. Because of these serious infectious complications, he was treated with mepolizumab instead of corticosteroids for the ABPM, which resolved all symptoms and clinical features. This case highlights mepolizumab treatment as an alternative to corticosteroid therapy for treatment of ABPM in patients with comorbidities such as infection.

A 67-year-old woman with a history of poorly controlled asthma was admitted to our hospital with a persistent cough and abnormal chest radiographic findings. Her diagnosis was allergic bronchopulmonary aspergillosis (ABPA). Following treatment with mepolizumab, her symptoms and imaging findings improved initially. However, after approximately 2 years, the patient experienced a recurrent cough with elevated non-specific immunoglobulin E levels and worsening chest imaging findings, thereby changing her diagnosis to recurrent ABPA. Mepolizumab was substituted with dupilumab, and her subjective symptoms and imaging findings improved. Our findings suggest that dupilumab may be effective in ABPA cases following the failure of another antibody therapy. • Humanized monoclonal antibodies are effective in patients with ABPA and may serve as a viable substitute for prednisolone. • Humanized monoclonal antibodies exhibit initial efficacy against ABPA; however, their effectiveness may attenuate over time. • Dupilumab may be effective in ABPA cases following the failure of another antibody therapy. [ABSTRACT FROM AUTHOR]

Abstract A 56-year-old woman was referred to our hospital for recurrent asthma of 20 years duration. She was diagnosed as having allergic bronchopulmonary aspergillosis on the basis of clinical symptoms, peripheral blood eosinophilia, elevated total serum immunoglobulin E value, positive results of specific IgE and precipitating antibodies against Aspergillus sp., central bronchiectasis, and mucoid impaction. Systemic corticosteroids and anti-fungal therapy improved her symptoms, but the cessation of these treatments led to frequent exacerbations. Omalizumab improved her asthmatic symptoms to the point that corticosteroids could be stopped; however, radiological findings were not improved, and coexisting eosinophilic sinusitis and otitis media worsened. After her treatment was changed from omalizumab to mepolizumab, not only her asthmatic symptoms but also her sinusitis and otitis media became well controlled, and chest radiological findings improved. [ABSTRACT FROM AUTHOR]

Severe Asthma (SA) is characterized by inadequate disease control despite maximal inhalation therapy. In November 2021, a 68-years old female patient presented at our facility referring a worsening in her asthma-related symptoms and a high exacerbations rate. She reported a liver transplantation in 2015 and was in treatment with tacrolimus. We started treatment with Mepolizumab 100 mg once every 28 days and monitored her lung function as well as her lymphocytes subsets. After one year follow-up, the patient had a substantial improvement in lung function, exacerbation rate, daily OCS intake dose and no variation in the blood concentration of tacrolimus. [ABSTRACT FROM AUTHOR]

Allergic bronchopulmonary aspergillosis (ABPA) is an allergic reaction caused by the fungus Aspergillus , and it is often treated with steroids or antifungal agents. However, long-term use of these medications can lead to infections and drug interactions. We present the case of a 71-year-old woman with ABPA who was diagnosed with hepatitis B and active hepatitis C, and sputum analysis revealed the presence of bacteria. Oral steroids were initially administered, but the patient was switched to mepolizumab because of numerous infectious complications. The early introduction of mepolizumab is effective in patients with ABPA complicated by infectious diseases. [ABSTRACT FROM AUTHOR]

Abstract Here we report on a 61-year-old man with refractory eosinophilic granulomatosis with polyangiitis (EGPA) who presented with dyspnea. Despite treatment with glucocorticoids, intravenous cyclophosphamide, and plasma exchange, his symptoms worsened despite his eosinophil count and myeloperoxidase antineutrophil cytoplasmic antibody titer trending downwards. EGPA with diffuse alveolar hemorrhage was diagnosed on analysis of bronchoalveolar lavage fluid. The patient was treated with rituximab and methylprednisolone pulse therapy and a remission was achieved. He has been receiving mepolizumab since then and remains in remission. It should be recognized that refractory diffuse alveolar hemorrhage can occur in patients with EGPA without elevation of biomarkers if they are receiving systemic corticosteroids. [ABSTRACT FROM AUTHOR]

A 26-year-old female with steroid dependent eosinophilic asthma and nasal polyps who had successfully been treated with mepolizumab for 17 consecutive months with complete steroid withdrawal and symptoms control, stopped biologic treatment due to pregnancy efforts. Mepolizumab discontinuation resulted in frequent exacerbations and daily symptoms despite high dose ICS/LABA and re-initiation of oral steroids. Mepolizumab was initiated again, followed by improvement of asthma control and gradual withdrawal of steroids within 2 months. The patient became pregnant during the fourth month of mepolizumab re-initiation. The patient presented two asthma exacerbations during pregnancy treated with short course (3 days) oral steroids and delivery was uneventful (female, Apgar 9, weight 2750 g, length 59 cm) in week 40 by caesarean section. [ABSTRACT FROM AUTHOR]

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. • Systemic corticosteroids are the standard treatment for ABPA. • ABPA often recurs and requires prolonged courses of corticosteroids. • We successfully treated a recurrent ABPA case by changing mepolizumab to dupilumab. • Dupilumab can be used as an alternative for prednisolone for treating ABPA. [ABSTRACT FROM AUTHOR]

We report the case of a 50-year-old man with allergic bronchopulmonary mycosis (ABPM) complicated with bilateral septic arthritis of the knees caused by Methicillin-resistant Staphylococcus aureus (MRSA). He had a background of bronchial asthma and end-stage renal failure on maintenance dialysis. He was treated with 30 mg/day of prednisolone for 14 days for ABPM. He developed bilateral septic arthritis of the knees, caused by MRSA during prednisolone treatment. He underwent bilateral arthroscopic washout with a 2-week course of intra-articular arbekacin, concomitantly treated with a 6-week course of intravenous teicoplanin and oral rifampicin, subsequently followed by oral linezolid treatment. However, he suffered exacerbation of ABPM during treatment of septic arthritis. Because of these serious infectious complications, he was treated with mepolizumab instead of corticosteroids for the ABPM, which resolved all symptoms and clinical features. This case highlights mepolizumab treatment as an alternative to corticosteroid therapy for treatment of ABPM in patients with comorbidities such as infection. [ABSTRACT FROM AUTHOR]

Severe asthma affects between 5 and 10% of patients with asthma worldwide and requires best standard therapies at maximal doses. A subgroup of patients remains refractory to all treatments. We describe two case reports with severe allergic asthma who progressively worsened over the years despite the best therapy. The patients were first treated with omalizumab, which was completely ineffective, and then with bronchial thermoplasty (BT), again without clinical benefit. Since our patients met the AIFA criteria for inclusion in mepolizumab treatment, a therapy with this anti-IL5 biological agent was initiated. In the first case (a 53-year-old female), after the second mepolizumab administration, symptoms improved progressively, with a reduction in the number and severity of exacerbations, so the patient could finally be discharged from hospital. At follow-up, it was possible to reduce oral corticosteroids and continuing with inhaled corticosteroids/long-acting beta-agonists and montelukast. The patient had only one exacerbation/year. Symptom control and quality of life improved significantly. In the second case report (a 55-year-old male), after the sixth mepolizumab administration, symptoms improved progressively, with a reduction in the number and severity of exacerbations. At follow-up, it was possible to reduce and stop oral corticosteroids, continuing with inhaled therapy and montelukast. Symptom control and quality of life improved significantly.These are the first cases of patients unresponsive to sequential omalizumab and BT but with good and prolonged clinical response to mepolizumab. Both cases suggest that also after the failure of two consecutive third-line treatments, a third treatment (mepolizumab) should be attempted. [ABSTRACT FROM AUTHOR]

Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction that is associated with an allergic immunological response to Aspergillus species via Th2-related inflammation. The long-term use of a systemic corticosteroid is often needed for the treatment of ABPA. However, systemic corticosteroid treatment imposes a risk of the onset of a nontuberculous mycobacterial infection. Here we report the case of a patient with ABPA who required the long-term use of an oral corticosteroid because her repeated asthmatic attacks were successfully treated with mepolizumab, an anti-interleukin-5 monoclonal antibody. The patient, a 60-year-old Japanese female, had been treated with an oral corticoid and itraconazole. Despite the success of the initial treatment for ABPA, it was difficult to discontinue the use of the oral corticosteroid. In addition, Mycobacterium avium was detected from her bronchial lavage. We initiated mepolizumab treatment to taper the amount of corticosteroid and control the asthma condition. The patient's number of blood eosinophils, serum IgE level, fractional exhaled nitric oxide level, dosage of oral prednisolone, and need for inhaled budesonide/formoterol all improved, without an exacerbation of her asthma attacks. Although further research regarding mepolizumab treatment is needed, we believe that mepolizumab could be considered one of the agents for treating refractory ABPA. [ABSTRACT FROM AUTHOR]

We described three severe asthmatics whose asthma symptoms were rapidly improved by benralizumab following favorable response to mepolizumab. Benralizumab-induced eosinophil depletion contributed to clinical improvement of severe asthma after mepolizumab-induced eosinophil reduction; thus, prior favorable responses to mepolizumab may predict benralizumab efficacy. [ABSTRACT FROM AUTHOR]