D3.432 - Severe chronic rhinosinusitis - diagnostic and therapeutic challenges, personalized approach and place of biological treatment: a clinical case

Chronic rhinosinusitis (with or without nasal polyps) is а common heterogeneous inflammatory disease, which based on dominant pathophysiological mechanisms and cytokine profiles, is classified into three endotypes, corresponding to Th1-, Th2-, and Th17-mediated inflammation. In many patients mixed inflammatory profiles may coexist.

In the absence of optimal control, the disease can significantly impair patients’ quality of life. While patients with CRSwNP can be successfully treated with biologic therapy, therapeutic options for patients with severe CRSsNP remain limited. However, growing evidence from clinical trials and individual case reports suggests potential efficacy of therapy with dupilumab in patients with CRSsNP, еspecially in those with type 2 inflammatory involvement.

We present the case of a 40-year-old female with severe CRS without endoscopic evidence of nasal polyposis, but with CT–confirmed polypoid hyperplasia of the maxillary sinuses (baseline modified Lund–Mackay score=13). The disease course was severe, with persistent nasal obstruction, rhinorrhea, postnasal drip and loss of smell, refractory to standard intranasal corticosteroid therapy. Paraclinical findings suggested a type 2 inflammatory endotype, including elevated baseline total IgE (209 IU/mL), increased FeNO (33 ppb), and eosinophilia on nasal cytology during follow-up (up to 50 cells/µL). The blood eosinophil count remained within the normal range (100–200 cells/µL). The patient had no comorbid bronchial asthma.

Although the patient did not formally meet the criteria for biologic therapy, her immunological profile supported the presence of a type 2 inflammatory endotype. Consequently, dupilumab was initiated in April 2025 at a dose of 300 mg and administered at irregular intervals due to limited drug availability (a total of seven doses).

А rapid and marked clinical response was observed, with resolution of symptoms within several days after administration. A significant improvement in quality of life was documented, measured by a reduction in SNOT-22 score from 62 to 3 points. The clinical response is comparable to previously published data from clinical trials and isolated case reports. Despite the irregular dosing schedule, the patient had an asymptomatic period of approximately 1.5 months after each 300 mg dupilumab administration.

This clinical case supports the growing evidence that dupilumab may be an effective treatment option in selected patients with severe CRSsNP and type 2 inflammation. Further studies are needed to better define this patient subgroup and to expand indications for biologic therapy. Additionally, the optimal effective dosing interval should be investigated, including evaluation of extended dosing regimens.