Key message
It is an absolute necessity to achieve complete control of comorbidities to obtain optimal asthma control. Importantly, type 2 asthma and ECRS share the same inflammatory pathophysiology and are common co‐morbidities. If the initial biologic is insufficiently effective, it is worth considering an alternative biologic.
Keywords: asthma, benralizumab, dupilumab, mucus plug, nasal polyp
This case illustrates that it is an absolute necessity to achieve complete control of comorbidities to obtain optimal asthma control. Importantly, type 2 asthma and eosinophilic chronic rhinosinusitis (ECRS) share the same inflammatory pathophysiology and are common co‐morbidities. If the initial biologic is insufficiently effective to control asthma, it is worth considering an alternative biologic.
CLINICAL IMAGE
The present case was a 33‐year‐old woman with severe asthma and eosinophilic chronic rhinosinusitis (ECRS). Despite treatment with high‐dose inhaled steroids, long‐acting bronchodilators, and leukotriene antagonists for several years, she had a wet cough and had lost most of her sense of smell. Her asthma control test (ACT) score was 15. Biomarkers of type 2 inflammation were immunoglobulin E, 61 IU/mL (normal, < 361 IU/mL); peripheral blood eosinophils, 336/μL; and FeNO, 187 ppb. Chest computed tomography (CT) showed mucus plugs (Figure 1A1). Mucus score was seven. 1 Sinus CT showed soft shadows in the maxillary and ethmoidal sinuses (Figure 1B1). Lund–Mackay score was 17. Benralizumab was started as additional therapy. After 10 months of benralizumab administration, her ACT score improved from 15 to 19, mucus score from 7 to 4, and Lund–Mackay score from 17 to 10 (Figure 1B2). However, the loss of sense of smell and wet cough persisted, and chest CT showed a slightly enlarged residual mucous plug (Figure 1A2). Two months after switching from benralizumab to dupilumab, the ACT score improved from 19 to 25, mucus score from 4 to 2, and Lund–Mackay score from 10 to 6 (Figure 1B3). Chest CT showed disappearance of the residual mucus plug (Figure 1A3). It is an absolute necessity to achieve complete control of comorbidities to obtain optimal asthma control. Importantly, type 2 asthma and ECRS share the same inflammatory pathophysiology and are common co‐morbidities. 2 As dupilumab has been shown to be effective in both type 2 asthma and chronic sinusitis with nasal polyps, 2 it is an effective treatment option. Although benralizumab has shown efficacy for mucus plugs, 3 the response may be inadequate in some patients, as in the present case. An alternative biological therapy can be considered in such cases.
FIGURE 1.
Computed tomography (CT) images showing change in the appearance of a mucus plug and eosinophilic chronic rhinosinusitis before and after administration of biologics. (A1) CT of the chest obtained before biologics administration shows a large mucus plug (arrow). Mucus score is seven. (A2) CT of the chest obtained after 10 months of benralizumab administration shows a slightly enlarged residual mucous plug (arrow). Mucus score is four. (A3) CT of the chest obtained 2 months after switching from benralizumab to dupilumab shows disappearance of the residual mucus plug (arrow). Mucus score is two. (B1) CT of the sinuses obtained before biologics administration shows soft shadows in the maxillary and ethmoidal sinuses. Lund–Mackay score is 17. (B2) CT of the sinuses obtained after 10 months of benralizumab administration shows partial disappearance of the soft shadows in the right maxillary sinus. Lund–Mackay score is 10. (B3) CT of the sinuses obtained two months after switching from benralizumab to dupilumab shows disappearance of the soft shadows in the left maxillary sinus. Lund–Mackay score is 6.
AUTHOR CONTRIBUTIONS
MH wrote the manuscript. MH and TI contributed to data collection. All authors read and approved the final manuscript.
CONFLICT OF INTEREST STATEMENT
None declared.
ETHICS STATEMENT
The authors declare that appropriate written informed consent was obtained for the publication of this manuscript and accompanying images.
ACKNOWLEDGMENTS
The authors thank FORTE Science Communications (https://www.forte-science.co.jp/) for English language editing.
Hamakawa M, Ishida T. Benralizumab‐resistant mucus plugs in severe asthma complicated by eosinophilic chronic rhinosinusitis. Respirology Case Reports. 2024;12(8):e70009. 10.1002/rcr2.70009
Associate Editor: Francesca Gonnelli
DATA AVAILABILITY STATEMENT
Research data are not shared.
REFERENCES
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Research data are not shared.