D1.128 - Dupilumab in a Child with Severe Allergic Asthma, Atopic Dermatitis, Vernal Keratoconjunctivitis, and Partial IgA Deficiency
Case report
Dupilumab is an anti-IL4 medication used to control atopic dermatitis (AD) and reduce exacerbations of severe asthma.
We evaluate the role of dupilumab in a 14-year-old child with severe allergic asthma, moderate AD, vernal keratoconjunctivitis (VKC), and partial IgA deficiency: 1-year follow-up.
The patient, born at term with appropriate birth weight and uncomplicated delivery, presented with the following conditions:
Asthma: Since approximately 3 years of age, the patient experienced 2 episodes per year of wheezing due to respiratory infections, along with allergic rhinitis and asthma sensitization to inhaled allergens.
AD: Since 4 years of age, the patient developed mild-to-moderate AD, managed with moisturizing therapy and cycles of local corticosteroids, with an SCORAD score <40.
VKC: Diagnosed in September 2017, treated with 1% cyclosporine eye drops until 2019, followed by good control until 2023 with antihistamines and local corticosteroids.
IgA Deficiency: A partial IgA deficiency was diagnosed in 2017, with levels ranging between 24 and 36 mg/dl and IgG levels below the normal range, but without severe respiratory or skin infections.
In February 2024, after a chest CT scan (showing no bronchiectasis), the patient, who had been on long-term asthma treatment with corticosteroids, long-acting inhaled bronchodilators, and oral leukotriene antagonists for about 6 years, began experiencing repeated exacerbations. The patient started treatment with dupilumab 300 mg every 2 weeks.
Since then, there has been a reduction in asthma exacerbations (two episodes in the first 4 months, one milder episode in the following 8 months), good control of AD with a reduction in the need for local therapy, but no improvement in VKC, particularly in the left eye, for which cyclosporine 0.1% eye drops were resumed.
Since January 2025, an attempt was made to extend the intervals between Dupilumab administrations from two to three weeks. However, due to an asthma exacerbation and the mild reactivation of atopic dermatitis (AD), the dosing schedule was reverted back to every two weeks.
Laboratory tests showed an increase in circulating eosinophils from 760/mm³ prior to treatment in January 2024, to 1650/mm³ in September, which decreased to 1040/mm³ in December 2024.
The continuation of dupilumab therapy is under review, as it has proven effective for AD and asthma exacerbations but only minimally effective for VKC, in the context of a partial IgA deficiency that has remained unchanged during treatment.
CONCLUSIONS: The future perspective is to assess how and when to continue dupilumab therapy, potential combinations or shifts to other biologics, and an effective treatment approach for all clinical phenotypes (asthma, AD, VKC), while considering the impact on immunological IgA deficiency, as required by personalized medicine.
