Three Biologic-Naïve Patients with Allergic Bronchopulmonary Aspergillosis Showing Significant Clinical Improvement with Tezepelumab

Abstract

Allergic bronchopulmonary aspergillosis is characterized by hypersensitivity to Aspergillus spp. and often causes intractable asthma. Studies have been conducted on biologics administered to patients with allergic bronchopulmonary aspergillosis; however, treatment may not always be successful. This may be due to the limitations of the current biologics that selectively target a single cytokine. Tezepelumab, a human monoclonal antibody that blocks the activity of thymic stromal lymphopoietin, broadly suppresses type 2 inflammation by regulating the upstream cascade of airway inflammation. Therefore, it is expected to have favorable effects in patients with allergic bronchopulmonary aspergillosis. We report three cases of allergic bronchopulmonary aspergillosis with uncontrolled symptoms despite the maximal use of conventional anti-asthmatic drugs such as inhalative agents, anti-leukotriene receptor antagonists, and antifungal drugs. None of the patients had previously received biologics. The addition of tezepelumab produced a marked clinical response in all three patients, which included fewer exacerbations and a reduced dosage of oral systemic corticosteroids and/or reduced as-needed short-acting beta-2 agonists. The patients' pulmonary symptoms were better controlled, peripheral blood eosinophil counts and immunoglobulin E levels decreased, and quality of life scores and respiratory function parameters improved. Mucous plugs accompanied by atelectasis and infiltrative shadows observed on chest computed tomography also improved. Tezepelumab may be a promising treatment option for allergic bronchopulmonary aspergillosis in patients with severe asthma, offering effective symptom control and enabling reduction in systemic corticosteroid use.

Keywords: mucous plug; peripheral blood eosinophilia; severe asthma; type 2 inflammatory biomarker.

Figure 1

Course of asthma control test (ACT) score and peripheral blood eosinophil counts. (A) Case 1: Clinical course of a 55-year-old woman before and 4, 8, 12, and 16 weeks after tezepelumab administration. (B) Case 2: Clinical course of a 63-year-old man before and 4, 8, 12, and 16 weeks after tezepelumab administration. (C) Case 3: Clinical course of a 69-year-old woman before and 4, 8, 12, and 16 weeks after tezepelumab administration. Solid lines represent peripheral blood eosinophil counts, and dashed lines represent ACT scores.

Figure 2

Computed tomography (CT) of three patients with allergic bronchopulmonary aspergillosis before and after tezepelumab administration. (A) Case 1: Chest CT images of a 55-year-old woman before and 24 weeks after tezepelumab administration. (B) Case 2: Chest CT images of a 63-year-old man before and 24 weeks after tezepelumab administration. (C) Case 3: Chest CT images of a 69-year-old woman before and 24 weeks after tezepelumab administration. Left panel: pre-tezepelumab; right panel: post-tezepelumab. Arrowheads indicate mucous plugs, pulmonary infiltration, or atelectasis.