An 81-year-old woman presented to our hospital due to an abnormal shadow on a chest X-ray and a 4-week-old
persistent cough. Laboratory examination revealed increased serum eosinophils and
immunoglobulin E. The
Asthma Control Test (ACT) score and forced expiratory volume in 1 sec indicated
airway obstruction. Chest computed tomography (CT) revealed mucoid impaction in the dilated left-lingular lobar bronchus. She was diagnosed with
bronchial asthma and treated with a high-dose inhaled
corticosteroid/long-acting β2 agonist. Two months later, her mucoid impaction in the CT image worsened; moreover, bronchoscopy revealed the white mucus plug with Charcot-Leyden crystals and filamentous fungi. The patient was diagnosed with
Allergic bronchopulmonary aspergillosis (ABPA) and treatment with 30 mg/day
prednisolone was started. Both the blood eosinophil count and the chest image improved almost substantially, and the
steroid was discontinued after a year. Sixteen months after cessation of
prednisolone treatment, peripheral
eosinophilia and mucoid impaction in the left B3b recurred. For the treatment of
bronchial asthma and recurrent ABPA, administration of
mepolizumab was initiated. Subsequently, although her peripheral eosinophils count decreased, chest CT showed expansion of the mucoid impaction and
IgE increased despite
mepolizumab treatment. Alternative
subcutaneous injection therapy with
dupilumab improved chest image, serum
IgE level, and her ACT score. After changing from
mepolizumab to
dupilumab, her ABPA,
asthma, and pulmonary function improved remarkably. This case illustrates the potential utility of
dupilumab for ABPA without re-administration of oral
prednisolone. Additional research is needed to identify an effective
therapy for ABPA with
asthma.