Effectiveness of omalizumab in an asthmatic patient with severe airway and blood eosinophilia

Omalizumab is a monoclonal antibody raised against class E immunoglobulin (IgE), approved for the treatment of chronic severe (in the EU) or moderate-to-severe (in the USA) IgE-mediated asthma. Omalizumab is effective in reducing asthma exacerbations, hospitalizations and emergency visits due to exacerbations as well as in improving patients’ quality of life (QoL) [1–3].
Here we report on a 41-year-old man suffering from severe allergic asthma with systemic and airway eosinophilia, despite using high-dose systemic corticosteroids. The disease began at the age of 36 with cough, dyspnea and poor exercise tolerance. The therapy included high-dose inhaled corticosteroids (ICS) in combination with long-acting 2-agonists (LABA), antileukotriene antagonists and rescue short acting 2-agonists (SABA). From the beginning, the disease has been severe and uncontrolled. Since 2011, dyspnea had been so severe that the patient permanently received 16 mg of methylprednisolone per day. Reduction of this dose ended up with a loss of asthma control. Moreover, the patient underwent functional endoscopic sinus surgery, due to turbinate hypertrophy.
In 2012, the patient was referred to our Department for a thorough diagnostic assessment. A 2-week washout from oral corticosteroids (OCS) was performed. On admission, the patient complained of significant breathlessness, wheezing, persistent productive cough and substantial limitation of exercise capacity. Physical examination revealed soft vesicular sound with a prolonged expiratory phase, numerous wheezes and rhonchi. Spirometry showed severe airflow limitation (FEV1 = 1.47 l (36% of a normal value (N)), FVC = 4.15 l (88% N), FEV1%FVC = 35.42%); reversibility test with bronchodilator was negative. Skin prick tests were positive for house dust mites and Alternaria sp. A class 2 specific IgE level was determined for Alternaria sp. by ELISA.
The blood eosinophil count was significantly increased (EO = 1.7 × 103/µl – 15.9% of white blood cells). Bronchoscopy revealed thick secretions covering bronchi and a very high airway eosinophilia (EO = 56.2%), as measured in bronchoalveolar lavage. Additional tests excluded parasites and protozoans infection as well as hypereosinophilic syndrome.
The final diagnosis at discharge was persistent severe asthma associated with chronic rhinosinusitis.
The patient was deemed to qualify for omalizumab treatment but due to reimbursement problems he could start this...


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