C3-02 Successful Management of Refractory Allergic Bronchopulmonary Aspergillosis With Dupilumab in a Teenager With Severe Asthma

Introduction

Allergic bronchopulmonary aspergillosis (ABPA) is an uncommon type 2 (Th2) hypersensitivity reaction to Aspergillus fumigatus. The mainstay of management has been with oral corticosteroids (OCS) and antifungals. In addition to their significant side effects, these therapies often yield variable responses: some experience persistent or recurrent symptoms, while others become steroid dependent. This has led to a growing interest in the use of biologics targeting Th2 inflammation for the management of ABPA. Here, we present a case of an adolescent with severe asthma and refractory ABPA who was successfully managed with dupilumab, a monoclonal antibody that targets the IL-4 receptor alpha subunit.

Case

A 14-year-old female with eosinophilic allergic asthma, allergic rhinitis, depression, and anxiety presented with worsening symptoms and daily albuterol use over six months, despite being on an inhaled corticosteroid/long-acting beta-agonist and a long-acting muscarinic antagonist. Initial evaluation demonstrated poor asthma control as illustrated in Figure 1. Following further workup, a diagnosis of ABPA was established according to current guidelines based on an elevated total IgE of 2,150 IU/mL, eosinophilia of 900 cells/μL, A. fumigatus-specific IgE of 0.51 kU/L, and an abnormal chest computed tomography demonstrating multi-lobar bronchiectasis, scattered mucus plugging, and mosaic attenuation. The patient was initially started on daily OCS. Despite more than 4 weeks of OCS treatment, her daily symptoms remained unchanged. Antifungal therapy was considered but deferred due to potential drug interactions, so dupilumab was initiated. Four weeks later, the patient described improvement in her symptoms, and an OCS taper was initiated. By twelve weeks, she had completely discontinued OCS, and she reported significant clinical improvement, with resolution of daily symptoms and decreased albuterol use. Her pulmonary function testing, FeNO, and total IgE demonstrated a consistent improvement (Figure 1).

Discussion

Limited evidence suggests that biologics targeting Th2 inflammation can improve symptom control, reduce OCS requirements, and decrease exacerbation rates associated with ABPA, although this has mainly been reported for omalizumab. Because total IgE levels during ABPA often exceed the upper limit of nomogram-based dosing for omalizumab and this drug has a less favorable safety profile compared to other biologics, there has been a recent interest in exploring other monoclonal antibodies for the management of ABPA. To our knowledge, only one other published case has described the successful use of dupilumab for ABPA in a pediatric patient. Our case adds to the limited pediatric evidence supporting the consideration of dupilumab in children with refractory ABPA.

This abstract is funded by: None