D1.116 - Severe Airflow Limitation Unmasked by NSAID Hypersensitivity: A Case of Undiagnosed Persistent Asthma with Nasal Polyposis

NSAID-exacerbated respiratory disease (N-ERD) is a complex condition characterized by asthma, chronic rhinosinusitis with nasal polyposis (CRSwNP), and hypersensitivity to NSAIDs. This case illustrates an 86-year-old patient with longstanding unrecognized severe airway obstruction, unveiled after an anaphylactic reaction to ibuprofen.

An 86-year-old male, never-smoker, with a history of mild persistent asthma and CRSwNP (grade 3-4), controlled on low-dose inhaled corticosteroids/long-acting beta-agonists (ICS/LABA), was referred for suspected NSAID hypersensitivity. He experienced sudden-onset dyspnea, oxygen desaturation (55%), nausea, and general malaise within minutes of ibuprofen ingestion, requiring emergency advanced life support. He received intravenous corticosteroids (200 mg hydrocortisone, 60 mg methylprednisolone), antihistamines, oxygen therapy, and aerosolized bronchodilators. Tryptase levels were normal. He was hospitalized for severe asthma exacerbation and discharged with baseline SpO₂ 95%. 

On allergy evaluation, prior NSAID tolerance was uncertain, and he had since avoided them. He tolerated paracetamol 1 g. Nasal congestion was chronic, partially relieved by intranasal corticosteroids. Despite 25 years of diagnosed asthma, he had not perceived dyspnea and only increased ICS/LABA doses during colds. 

Spirometry revealed severe obstruction: FEV1/FVC 34.39%, FEV1 0.68 L (47%), FVC 1.97 L (90%), with unmeasurable FeNO. ACT score was 25. Skin prick tests for inhalants and NSAIDs were negative. Chest X-ray was unremarkable. Given the high-risk surgical profile and severe uncontrolled CRSwNP, a multidisciplinary decision was made to initiate dupilumab, which was approved for both asthma and nasal polyposis. 

The patient began dupilumab 600 mg SC (loading), then 300 mg biweekly three months post-admission. Initial symptom burden: global nasal score 9-10/10, NOSE score 10/10, ACT 14. After three months, ACT improved to 18, with significant symptomatic relief. A repeat spirometry is pending.

This case highlights how NSAID hypersensitivity revealed an unrecognized severe obstructive airway disease, likely due to poor symptom perception. Despite severely impaired lung function (FEV1 47%), the patient denied dyspnea until the reaction. Dupilumab showed early benefits in asthma control and CRSwNP. This underscores the importance of screening for undiagnosed airflow limitation in patients with chronic rhinosinusitis and suspected NSAID hypersensitivity.