Successful treatment with dupilumab in mepolizumab-resistant allergic bronchopulmonary aspergillosis

Abstract

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.

Keywords: Allergic bronchopulmonary aspergillosis; Asthma; Dupilumab; Mepolizumab; Prednisolone.

Fig. 1

Findings of chest computed tomography (CT) on admission. (A, B, and C) CT scans showing nodules in both upper lobes and an infiltrating shadow in the right middle lobe. (D) CT scan showing high-attenuation mucus (HAM) in the middle lobe bronchus (arrowhead).

Fig. 2

Clinical course of the patient. CT, computed tomography; ACT, Asthma Control Test; Eos, eosinophil; IgE, immunoglobulin E; PSL, prednisolone.

Fig. 3

Chest computed tomography imaging during the clinical course. (A) Before treatment, nodules were observed in the right upper lobe and an infiltrating shadow along with mucoid impaction was observed in the right middle lobe. (B) After 6 months of prednisolone treatment, the nodules, infiltrating shadow, and mucoid impaction resolved. (C) Four years after the prednisolone treatment, the nodules recurred in the right upper lobe, and the infiltrating shadow and mucoid impaction recurred in the right lower lobe. (D) After treatment with mepolizumab, the nodules and infiltrating shadow improved. (E) After 2 years of mepolizumab treatment, atelectasis of the right middle lobe was observed (circle). (F) Following treatment with dupilumab, atelectasis of the right middle lobe resolved, resulting in the presence of traction bronchiectasis (dotted circle).