The presence of fungal-specific IgE in serum and sinonasal tissue among patients with sinonasal polyposis

Dupilumab: An emerging therapy in allergic fungal rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) is a highly resistant disease and is challenging to treat. Patients with recurrent attacks of the disease despite surgical management can benefit from biologics as adjunct therapies. Dupilumab has shown promising endpoints in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP). This case series reports 4 patients with resistant AFRS concomitant with asthma, for which dupilumab therapy was administered. Long-term follow-ups showed that dupilumab improved the symptoms and improved the results of objective tools such as imaging and pulmonary function test.

Pediatric allergic fungal rhinosinusitis: optimizing outcomes

PURPOSE OF REVIEW

Allergic fungal rhinosinusitis (AFRS) is a debilitating condition for children. Despite there being several reviews on this topic in the adult population, there is a paucity of reviews of AFRS in the pediatric literature. This article reviews the recent evidence of pediatric AFRS with the aim to optimize outcomes of pediatric patients with this condition.

RECENT FINDINGS

AFRS is clinically characterized by nasal polyposis, a type I hypersensitivity to fungal epitopes, very thick eosinophilic mucin, and peripheral eosinophilia. Pediatric AFRS has similar clinical characteristics to that in adults but is thought to have a more aggressive nature, with higher serum immunoglobulin E and more frequently bone erosion and malformation of facial bones. Diagnosis of pediatric AFRS is made by using the Bent and Kuhn's criteria developed for adult AFRS. The mainstay of treatment is surgery followed by postoperative corticosteroids. Adjunctive therapies, including topical/oral antifungal agents, allergen immunotherapy and biologics may improve outcomes in pediatric AFRS, but to date the current evidence is limited.

SUMMARY

To optimize the outcome of pediatric AFRS, adequate and early diagnosis and treatment are essential. Appropriate and comprehensive endoscopic sinus surgery to open the sinuses, remove the fungal burden of disease and improve access of the sinuses to postoperative topical corticosteroid remains the standard of care.

A case report of allergic fungal rhinosinusitis managed with Dupilumab

Introduction

Allergic fungal rhinosinusitis (AFRS) is a subtype of chronic rhinosinusitis with nasal polyps. It is characterized by eosinophilic mucin, which results from an inflammatory reaction to non-invasive fungal hyphae in the rhino-sinuses. It is clinically recognizable due to the criteria set by Bent and Kuhn. The treatment approach is multimodal, and the main treatment approach is surgical debridement, followed by a course of oral and/or topical corticosteroids to decrease recurrence post-surgery. This case report aims to illustrate the effect of Dupilumab, on the number of relapse episodes in a patient and the associated parameters.

Case presentation

Herein we report a case of a 40-year-old woman referred to our institution as a case of refractory AFRS for which she underwent four functional endoscopic sinus surgeries (FESS) and was on maximum medical treatment. She presented with complaints of facial fullness and pain, headache, and purulent discharge. After another trial of surgery which did not control her symptoms, she was assessed for criteria to start biological treatment. The symptoms were successfully controlled after initiation of the agent, and she was followed up using multiple subjective and objective measures.

Conclusion

AFRS is a non-invasive immune-mediated sub-clinical entity of chronic rhinosinusitis. A multimodal approach to its treatment based on surgical debridement with medical therapy has shown positive outcomes. In this case we present significant improvement after administering Dupilumab; therefore, suggesting its addition to the treatment regimen of refractory AFRS.

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Allergic fungal rhinosinusitis is a subtype of chronic rhinosinusitis with nasal polyps.

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The distinguishing feature of allergic fungal rhinosinusitis is high immunoglobulin E.

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Multimodal approach with the mainstay being surgery is the treatment method followed for allergic fungal rhinosinusitis.

A Review of Classification Schemes for Chronic Rhinosinusitis with Nasal Polyposis Endotypes

Objective

The recent development of endotypes to categorize disease variants of chronic rhinosinusitis (CRS) reflects an evolving understanding of the various pathophysiologic and pathogenetic mechanisms that contribute to the clinical heterogeneity of CRS manifestations. This review highlights popular endotype‐based criteria used to define different CRS with nasal polyposis (CRSwNP) subtypes and further discusses the emerging therapeutic advances for each classificatory approach.

Data Sources

PubMed literature review.

Methods

A review of the current literature was conducted to determine present‐day uses of immunologic and molecular profiles in the CRSwNP disease spectrum to identify specific endotypes.

Results

Four distinct but overlapping classification schemes have emerged to define endotypes within the CRSwNP phenotype: 1) type 2 cytokine‐based approach, 2) eosinophil‐based approach, 3) immunoglobulin (Ig)E‐based approach, and 4) cysteinyl based approach. The identification of key inflammatory biomarkers related to these CRSwNP endotypes has broadened the classification of CRS beyond common phenotypic expressions. Furthermore, CRSwNP endotypes may improve the selection of CRSwNP patients who are suitable candidates for biomarker‐specific treatment options, such as anti‐interleukin‐5; anti‐IgE; and platelet‐directed therapies.

Conclusion

Chronic rhinosinusitis endotyping with key biomarker patterns of inflammation allows for improved diagnostic and potentially therapeutic classifications of CRSwNP variants.