Q:

3/28/2012
I have a 27 years old female patient who has had allergic rhinitis and asthma for 9 years. She is allergic to house dust mite. She is on ICS/LABA treatment. There are two attacks of eosinophilic pneumonia in her history. The first attack was 5 years ago. The last one was 6 months ago. She was treated with 60 mg prednisolone. She received the last dose one month ago. Eosinophil number 890/uL. I am considering immunotherapy. Will immunotherapy be safe for her? Thank you.

A:

Thank you for your inquiry.

Eosinophilic pneumonia is not in itself an absolute contraindication to allergen immunotherapy per se. However, one form of eosinophilic pneumonia, the variety that is associated with allergic bronchopulmonary aspergillosis, is a theoretical contraindication to the administration of immunotherapy to mold antigens. This has been discussed on our website previously, and I have copied for you below a discussion of this issue contributed by Dr. Raymond Slavin.

Thus, it is important for you to define the cause, if you can, of the eosinophilic pneumonia that your patient has experienced. To help you with this, you might wish to consider another posting on our website dealing with eosinophilic pneumonia and its differential diagnosis. For your convenience, I have copied a link below to this response.

In summary, except for the issue of allergic bronchopulmonary aspergillosis and mold immunotherapy, I know of no further contraindication to immunotherapy in your patient. However, I do feel it is important to define the cause of eosinophilic pneumonia in your patient if you can do so.

Thank you again for your inquiry and we hope this response is helpful to you.

Question: I am treating a young college student with severe asthma. She was sent to me by a scholarly pulminologist for help in controlling her asthma from my atopic point of view. She was recently diagnosed with ABPA. She is on maximal medications with good compliance but poor control. Her IgE is too high for Xolair use. She had immunotherapy as a child and reports having a good response.

I was taught to not give IT in ABPA during fellowship. Is there any role for such for allergens other than Aspergillus fumigatus in such a case?

REPLY: I had my own thought as to how to respond to your question. However, I wanted to see what an expert in ABPA said about this matter. Therefore, I obtained input from Dr. Raymond Slavin of the St. Louis Univ. School of Medicine, an expert in ABPA. His thoughtful response is enclosed below.

Dr. Slavin's comments:

As usual, you express great insights. IT with antigens other than aspergillus can certainly be given in ABPA. They generally have many sensitivities other than to aspergillus. The only objection to using aspergillus is the theoretical one of giving an antigen to which the patient has a precipitating antibody with the possibility of creating an immune complex disease. This was predicated years ago by Jack Pepys and despite no evidence of this ever happening, people have shied away from including aspergillus in the treatment mix.

Title: Pulmonary infiltrates with eosinophilia
Posted: 12/19/2011
Link: http://www.aaaai.org/ask-the-expert/pulmonary-infiltrates-with-eosinophilia.aspx

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology