Monoclonal antibodies/corticosteroids
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Exacerbation of asthma and severe airway infections: 4 case reports In a case series, 4 patients (2 women and 2 men) aged 61–82 years were described, who developed Haemophilus influenzae infection, aspergillosis, Mycobacterium avium intracellulare, Streptococcus pneumoniae, Pseudomonas aeruginosa, Pneumocystis jiroveci or exacerbation of asthma during treatment with benralizumab, deflazacort, fluticasone furoate, fluticasone propionate, mepolizumab, methylprednisolone, prednisone or reslizumab for eosinophilic asthma [duration of treatments to reactions onsets not stated; not all routes, dosages and outcomes stated]. Case 1: A 61-year-old woman was followed since 2015 for bronchiectasis, severe eosinophilic asthma and previously treated allergic bronchopulmonary aspergillosis. Despite partial gastrectomy she had peptic ulcer disease causing chronic dyspepsia. Her medications included oral prednisone 15mg, inhalation fluticasone propionate 1000µg and salmeterol. In May 2018, she was initiated on mepolizumab, when her sputum eosinophil percentage was 3.5% and peak blood eosinophil count was 0.2 × 109/L. During this treatment, her prednisone dose was reduced to 5mg. In November 2018, she developed vomiting and significant weight loss with increasing sputum and cough. Initially, this was attributed to her ongoing GI disorders, although endoscopy revealed no abnormalities. Sputum differential cell counts revealed neutrophilic bronchitis with neutrophils 98.8% with a total cell count of 182 × 106 cells/g (exacerbation of asthma). A chest CT scan demonstrated right upper lobe cavity (3.5cm) containing an irregularly shaped opacity. Bronchoscopy was unremarkable; however, bronchoalveolar lavage (BAL) fluid grew Haemophilus influenzae. She was treated with an unspecified antibiotic, and her symptoms improved. A CT-guided biopsy of the cavity revealed necrotising granulomatous inflammation with fungi associated with a diagnosis of semi-invasive aspergillosis. As she was intolerant to itraconazole and voriconazole, she was treated with isavuconazole. Subsequently, radiological and clinical improvement was noted, and mepolizumab was stopped. Case 2: A 62-year-old man had eosinophilic asthma since 2013. In 2014, CT scan showed several millimetric nodules, mostly in the upper lobe. He was treated with fluticasone propionate 3000µg, oral prednisone 10mg, salmeterol 200µg daily; however, the sputum eosinophilia persisted. Hence, he was treated with mepolizumab and reslizumab between 2014 and 2018. A suboptimal response was achieved, but marked exacerbations consistent with sputum eosinophilia were noted. He was administered unspecified corticosteroids, and mepolizumab and reslizumab were switched to benralizumab. Over 8 months of the treatment, the dose of prednisone was reduced to 7.5mg and he continued to expectorate and cough. Thereafter, benralizumab was stopped, after which the sputum eosinophils elevated. In August 2019, a chest CT scan revealed several new and larger pulmonary nodules. The largest lesion measured 2.7cm
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