Case Report
Mepolizumab and Eosinophilic Pleural Effusion in Patient With Eosinophilic Granulomatosis With Polyangiitis
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(B) Computed axial tomography image of the abdomen with lesion in the 4th segment of the duodenum with adjacent lymph node blockage. (C) Computed axial tomography image of the chest showing a tumor in the posterior segment of the right upper lung lobe. Extensive bulbous emphysema in upper lobes.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Covadonga de la Escosura Muñoz, Débora Contreras Toledo, Tamara Hermida Valverde" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Covadonga" "apellidos" => "de la Escosura Muñoz" ] 1 => array:2 [ "nombre" => "Débora" "apellidos" => "Contreras Toledo" ] 2 => array:2 [ "nombre" => "Tamara Hermida" "apellidos" => "Valverde" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623001187?idApp=UINPBA00003Z" "url" => "/03002896/0000005900000007/v3_202310232131/S0300289623001187/v3_202310232131/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0300289623001205" "issn" => "03002896" "doi" => "10.1016/j.arbres.2023.03.020" "estado" => "S300" "fechaPublicacion" => "2023-07-01" "aid" => "3300" "copyright" => "SEPAR" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Arch Bronconeumol. 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] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carmen Fernández-Arias, Eduard Barrio-Herraiz, Carmen Centeno-Clemente, Ignasi García-Olivé, Rachid Tazi-Mezalek, Felipe Andreo-Garcia, Jorge Abad-Capa, Antoni Rosell-Gratacós, Pere Serra-Mitjà" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Carmen" "apellidos" => "Fernández-Arias" ] 1 => array:2 [ "nombre" => "Eduard" "apellidos" => "Barrio-Herraiz" ] 2 => array:2 [ "nombre" => "Carmen" "apellidos" => "Centeno-Clemente" ] 3 => array:2 [ "nombre" => "Ignasi" "apellidos" => "García-Olivé" ] 4 => array:2 [ "nombre" => "Rachid" "apellidos" => "Tazi-Mezalek" ] 5 => array:2 [ "nombre" => "Felipe" "apellidos" => "Andreo-Garcia" ] 6 => array:2 [ "nombre" => "Jorge" "apellidos" => "Abad-Capa" ] 7 => array:2 [ "nombre" => "Antoni" "apellidos" => "Rosell-Gratacós" ] 8 => array:2 [ "nombre" => "Pere" "apellidos" => "Serra-Mitjà" ] ] ] ] "resumen" => array:1 [ 0 => array:3 [ "titulo" => "Graphical abstract" "clase" => "graphical" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><elsevierMultimedia ident="fig0005"></elsevierMultimedia></p></span>" ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623001205?idApp=UINPBA00003Z" "url" => "/03002896/0000005900000007/v3_202310232131/S0300289623001205/v3_202310232131/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Mepolizumab and Eosinophilic Pleural Effusion in Patient With Eosinophilic Granulomatosis With Polyangiitis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "439" "paginaFinal" => "440" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "María del Carmen Lorenzo Martínez, Oscar Clavería García, María Dolores Herrero Mendoza, José Javier Jareño Esteban" "autores" => array:4 [ 0 => array:4 [ "nombre" => "María del Carmen" "apellidos" => "Lorenzo Martínez" "email" => array:1 [ 0 => "carmenlorenzomtz@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Oscar" "apellidos" => "Clavería García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "María Dolores" "apellidos" => "Herrero Mendoza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "José Javier" "apellidos" => "Jareño Esteban" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Pneumology Department, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Internal Medicine Department, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1014 "Ancho" => 2750 "Tamanyo" => 160423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest CT. Left image: bilateral pleural effusion predominantly on the left side with secondary passive atelectasis. Right image: bilateral infiltrates.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We present a 71-year-old woman with a long-standing history of severe eosinophilic asthma (por controlled with ACT scale of 15) and nasal polyposis, with suspected poor adherence to treatment at follow-up.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was admitted to our hospital with clinical manifestations of cough and whitish expectoration. During physical examination, partial respiratory failure and semiology of asthmatic exacerbation with hypophonesis in lower pulmonary lobes were found. X-ray, and then chest CT, were requested showing consolidation in the upper lobes and bilateral pleural effusion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Laboratory data showed no biochemistry alterations, NT-proBNP 262<span class="elsevierStyleHsp" style=""></span>pg/ml, CRP 2.62<span class="elsevierStyleHsp" style=""></span>mg/dl and leukocytosis 15,180/mcL (eosinophils 3.990/mcL, 27%). The ANAs, MPO-ANCA, PR3-ANCA, microbiology and serology were all negative (virus, bacteria and parasites).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In view of patient's poor respiratory progress, we performed a diagnostic thoracentesis, obtaining a yellowish non-hematic exudate with the following characteristics: pH 7.20, protein 6<span class="elsevierStyleHsp" style=""></span>g/dl, glucose 214<span class="elsevierStyleHsp" style=""></span>mg/dl, LDH 203<span class="elsevierStyleHsp" style=""></span>U/L and leukocytes 6780/mcL (50% eosinophils). Cytology and microbiology were negative. It was decided to carry out a nasal turbinate biopsy, that showed eosinophilic infiltration of the corium. Polyneuropathy was ruled out.</p><p id="par0020" class="elsevierStylePara elsevierViewall">EGPA was diagnosed classifying it as a nonsevere with a “Five Factor Score” (FFS) of zero. Treatment was started with prednisone 50<span class="elsevierStyleHsp" style=""></span>mg and mepolizumab 100<span class="elsevierStyleHsp" style=""></span>mg per day, progressively escalating to mepolizumab 300<span class="elsevierStyleHsp" style=""></span>mg per day. After 6 months of full-dose treatment, the patient presented an excellent clinical and radiological improvement with complete resolution of eosinophilic pleural effussion (EPE).</p><p id="par0025" class="elsevierStylePara elsevierViewall">According to <span class="elsevierStyleItalic">the American College of Rheumatology (1990</span>),<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> more than 4 of the next 6 criteria are necessary for EGPA diagnosis: asthma, peripheral eosinophilia (>10%), neuropathy, sinusitis, extravascular eosinophilia and evanescent pulmonary infiltrates. Eosinophilic pleural effusion is a rare complication,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> with an incidence of 29% in patients with EGPA. Its characteristics have not been well described, having been defined by more than 10% eosinophil count, low pH and low glucose. Differential diagnoses of EPE include rheumatoid arthritis, bacterial pneumonia, tuberculosis, parasitosis, pharmacological, neoplasms, hematological disorders and, less frequently, certain vasculitis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is no standard therapy for the management of EGPA.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Currently, the cornerstone of treatment consist of systemic glucocorticosteroids, with a relapse rate of 35%. In this context, immunosuppressive agents are used for maintaining remission. In spite of that, high dose of glucocorticoids and immunosuppressants may have long-term adverse effects. Recently, clinical benefits of mepolizumab have been demonstrated in patients with EGPA. MIRRA trial<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> included patients with refractory EGPA treated with prednisone, demonstrating remission in 87% of patients treated with mepolizumab versus 53% in the placebo group. An European Observacional Study compared mepolizumab 300<span class="elsevierStyleHsp" style=""></span>mg versus 100<span class="elsevierStyleHsp" style=""></span>mg dose, showing both doses are associated with effective control of systemic EGPA manifestations.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Therefore, mepolizumab is now a good therapeutic option for EGPA. It should be considered as a steroid-sparing drug used for maintenance of remission and control of non-organ-threatening flares, but not as a treatment for active organ-threatening disease.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1014 "Ancho" => 2750 "Tamanyo" => 160423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest CT. Left image: bilateral pleural effusion predominantly on the left side with secondary passive atelectasis. Right image: bilateral infiltrates.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The American College of Rheumatology 1990 criteria for the classification of Churg-Strauss syndrome (allergic granulomatosis and angiitis)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.T. Masi" 1 => "G.G. Hunder" 2 => "J.T. Lie" 3 => "B.A. Michel" 4 => "D.A. Bloch" 5 => "W.P. Arend" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/art.1780330806" "Revista" => array:6 [ "tituloSerie" => "Arthritis Rheum" "fecha" => "1990" "volumen" => "33" "paginaInicial" => "1094" "paginaFinal" => "1100" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2202307" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Massive eosinophilic pleural effusion preceding vasculitic symptoms in Churg-Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. Tanizawa" 1 => "Y. Kaji" 2 => "E. Tanaka" 3 => "T. Inoue" 4 => "M. Sakuramoto" 5 => "M. Minakuchi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2169/internalmedicine.49.2839" "Revista" => array:6 [ "tituloSerie" => "Intern Med" "fecha" => "2010" "volumen" => "49" "paginaInicial" => "841" "paginaFinal" => "845" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20453405" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2021 American College of Rheumatology/Vasculitis Foundation Guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.A. Chung" 1 => "C.A. Langford" 2 => "M. Maz" 3 => "A. Abril" 4 => "M. Gorelik" 5 => "G. Guyatt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/art.41773" "Revista" => array:6 [ "tituloSerie" => "Arthritis Rheumatol" "fecha" => "2021" "volumen" => "73" "paginaInicial" => "1366" "paginaFinal" => "1383" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34235894" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mepolizumab or placebo for eosinophilic granulomatosis with polyangiitis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.E. Wechsler" 1 => "P. Akuthota" 2 => "D. Jayne" 3 => "P. Khoury" 4 => "A. Klion" 5 => "C.A. Langford" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1702079" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2017" "volumen" => "376" "paginaInicial" => "1921" "paginaFinal" => "1932" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28514601" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mepolizumab for eosinophilic granulomatosis with polyangiitis: a European multicenter observational study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Bettiol" 1 => "M.L. Urban" 2 => "L. Dagna" 3 => "V. Cottin" 4 => "F. Franceschini" 5 => "S. Del Giacco" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/art.41943" "Revista" => array:6 [ "tituloSerie" => "Arthritis Rheumatol" "fecha" => "2022" "volumen" => "74" "paginaInicial" => "295" "paginaFinal" => "306" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34347947" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03002896/0000005900000007/v3_202310232131/S0300289623001138/v3_202310232131/en/main.assets" "Apartado" => array:4 [ "identificador" => "93562" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/0000005900000007/v3_202310232131/S0300289623001138/v3_202310232131/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289623001138?idApp=UINPBA00003Z" ]
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