Utilization of dupilumab in an immunocompromised patient with extensive allergic fungal rhinosinusitis unsuitable for surgical intervention: A case report.

INTRODUCTION

Allergic fungal rhinosinusitis (AFRS) is a distinct subset of chronic rhinosinusitis characterized by a type I hypersensitivity to fungi. Immunocompromised patients are at increased risk for fungal infections. This case highlights the complexities of managing AFRS in patients not eligible for surgery.

CASE PRESENTATION

We present a 32-year-old patient with a history of Wilson's disease and a previous liver transplant on immunosuppressive medications. The patient presented to our tertiary hospital with a year-long history of bilateral progressive nasal obstruction, along with diplopia, anterior and posterior rhinorrhea, intermittent numbness on the left side of her face, tinnitus and nausea. Initial imaging revealed extensive sinonasal disease with hyperdense components. FESS was performed, and biopsy and culture confirmed the diagnosis of AFRS. Notably, gross dehiscence of the carotid arteries was observed during surgery. Three and a half years after surgery, the patient experienced a relapse of symptoms after COVID-19 infection. Due to the risk of inadvertent damage to the carotid artery during surgery, the patient was offered a trial of dupilumab instead. The patient reported complete resolution of symptoms 6 months after starting dupilumab.

DISCUSSION

Given the significant surgical risks associated with carotid artery dehiscence, a trial of dupilumab was initiated. This biologic therapy, known for its efficacy in treating type 2 inflammatory conditions, resulted in a remarkable response, with complete resolution of symptoms within six months. Previous reports of dupilumab use in AFRS have yielded similar outcomes.

CONCLUSION

The case underscores the potential of dupilumab as a safe and effective alternative for managing recalcitrant AFRS, particularly in patients at high risk for surgical complications.