Coronavirus Disease 2019 Vaccine-Induced Flare-Up of Severe Bronchial Asthma Previously Controlled With Dupilumab: A Case Report.

The widespread after-effects of the coronavirus disease 2019 (COVID-19) are still a grave threat worldwide. Among them are adverse reactions to vaccines, including those most observed following Pfizer-BioNTech (BNT162b2) vaccine administration, namely, local reactions at the injection site, fatigue, headache, myalgia, chills, arthralgia, and fever. Patients with asthma particularly present with unique adverse reactions to the BNT162b2 vaccine, notably, an exacerbation in their asthma symptoms as highlighted through the current case report. In this case, a 50-year-old woman had been undergoing treatment for bronchial asthma in the form of inhalation steroids and dupilumab, as well as systemic steroid prednisolone as maintenance therapy. She had mild injection site reactions after her first three COVID-19 vaccinations. She also experienced acute exacerbation requiring hospitalization after the fourth and fifth doses. Her symptoms resolved following steroid therapy. The close association between the timing of vaccinations and the onset of clinical symptoms suggests that the exacerbation episodes were triggered by the vaccine. Therefore, although the BNT162b2 vaccine is safe to administer in patients with bronchial asthma, cases reporting patients sensitized to the BNT162b2 vaccine developing bronchial asthma or experiencing asthma exacerbations should not be neglected. Clinicians should be aware of the possibility of flare-ups induced by repeated COVID-19 vaccinations in such patients.

COVID-19-Associated Disease Course Is Shortened in Moderate-to-Severe Atopic Dermatitis Patients Receiving Dupilumab Treatment: A Retrospective Cross-Sectional Study.

Previous studies suggest that allergic diseases may be a protective factor in SARS-CoV-2 infection. However, data regarding the impact of dupilumab, a widely used immunomodulatory medication, on COVID-19 in an allergic population are very limited. To investigate the incidence and severity of COVID-19 among moderate-to-severe atopic dermatitis (AD) patients treated with dupilumab, a retrospective cross-sectional survey was conducted among patients with moderate-to-severe AD who presented at the Department of Allergy of Tongji Hospital from 15 January 2023 to 31 January 2023. Healthy individuals matched for gender and age were also enrolled as a control. All subjects were asked about their demographic characteristics, past medical history, COVID-19 vaccination history, and medications, as well as the presence and duration of individual COVID-19-related symptoms. A total of 159 moderate-to-severe AD patients and 198 healthy individuals were enrolled in the study. Among the AD patients, 97 patients were treated with dupilumab, and 62 patients did not receive any biologicals or systemic treatments (topical treatment group). The proportions of people who were not infected with COVID in the dupilumab treatment group, topical treatment group and healthy control group were 10.31%, 9.68% and 19.19%, respectively (p = 0.057). There was no significant difference in COVID-19-related symptom scores among all groups (p = 0.059). The hospitalization rates were 3.58% in the topical treatment group and 1.25% in the healthy control group, and no patient was hospitalized in the dupilumab treatment group (p = 0.163). Compared with healthy control group and topical treatment group, the dupilumab treatment group had the shortest COVID-19-associated disease duration (dupilumab treatment group, 4.15 ± 2.85 d vs. topical treatment group, 5.43 ± 3.15 d vs. healthy control group, 6.09 ± 4.29 d; p = 0.001). Among the AD patients treated with dupilumab for different times, there was no appreciable difference (<0.5 year group, 5 ± 3.62 d vs. 0.5-1 year group, 4.84 ± 2.58 d vs. >1 year group, 2.8 ± 1.32 d; p = 0.183). Dupilumab treatment shortened the duration of COVID-19 in patients with moderate-to-severe AD. AD patients can continue their dupilumab treatment during the COVID-19 pandemic.

A Rare Case of Delayed Hypersensitivity Following COVID-19 Booster Necessitating Treatment With Dupilumab.

Following vaccination, patients can develop symptoms of eczema flare, which could range from mild skin irritation and urticaria to diffuse skin involvement. Delayed immunologic reactions have been described in association with the novel mRNA COVID-19 vaccines and boosters. We report the case of an 83-year-old female who presented with widespread pruritic urticarial indurated papules on the arms, legs, and palms, sparing the face six months following the booster vaccine. She denied constitutional symptoms, new medications, recent illnesses, or new personal care products. Punch biopsy demonstrated acanthosis, spongiosis, and superficial and mild dermal perivascular lymphocytic infiltration with occasional eosinophils compatible with a dermal hypersensitivity reaction. The patient was admitted to the hospital due to the need for systemic steroids as well as IV antibiotics secondary to a superimposed bacterial skin infection in the setting of severe itching and skin injury; she was discharged on oral steroids with follow-up to dermatology and rheumatology. Delayed hypersensitivity reactions typically peak within four days following vaccination and may be observed with COVID-19 vaccines or boosters. However, reports remain limited, and people's history of eczema should not preclude them from receiving a COVID-19 vaccine that is both safe and effective.

Jahrestagung der Gesellschaft fur Padiatrische Pneumologie.

The proceedings contain 54 papers. The topics discussed include: cytokines in severe childhood asthma;transcriptional gene regulation of interleukin-6 in epithelial cells in viral-induced asthma exacerbation;assessment of the long-term safety and efficacy of dupilumab in children with asthma: LIBERTY ASTHMA EXCURSION;impulse oscillometry bronchodilator response in preschool children;pulmonary function in non-hospitalized adults and children after mild Covid-19;exhaled aerosols in PCR-confirmed SARS-CoV-2-infected children;early respiratory infectious diseases have an influence on the gut microbiome;comparison of three eradication treatment protocols for pseudomonas aeruginosa in children and adolescents with cystic fibrosis;neutrophilic airway inflammation in children with repaired esophageal atresia-tracheoesophageal fistula (EA/TEF);and multiplex immunofluorescence and multispectral imaging as a tool to evaluate host directed therapy.

A case of complete recovery in a hypereosinophilic dermatitis patient with dupilumab.

BACKGROUND: Hypereosinophilic dermatitis (HED) is a subtype of hypereosinophilic syndrome (HES). Glucocorticoids are preferred for treatment but carry substantial side effect profiles. Symptoms of HED may recur after systemic glucocorticoid tapering. As an interleukin-4 receptor (IL-4Rα) monoclonal antibody targeting interleukin-4 (IL-4) and interleukin-13 (IL-13), dupilumab might be an efficacious adjuvant therapy for HED. METHOD: We report a young male diagnosed with HED who suffered from erythematous papules with pruritus for over five years. Once reducing the dosage of glucocorticoid was, his skin lesions relapsed. RESULTS: After using dupilumab, the patient's condition significantly improved with the glucocorticoid dosing decreased successfully. CONCLUSION: In conclusion, we report a new application of dupilumab in HED patients, especially with difficulties in reducing the glucocorticoid dose.

Dupilumab as a steroid-sparing treatment option in pediatric severe asthma and chronic rhinosinusitis with nasal polyps

Case report Chronic rhinosinusitis with nasal polyps (CRSwNP) is a frequent comorbidity in severe asthma in adults. Both diseases share key pathophysiological mechanisms that can involve type-2 inflammatory pathways. However, this is an uncommon presentation in pediatric patients. Dupilumab, a fully human monoclonal antibody against IL-4Ralpha, inhibits IL-4/ IL-13 signaling, which are key drivers of type-2 inflammation and interfere with both eosinophilic and allergic pathways. It is approved for patients >= 12-year- old with moderate to severe uncontrolled asthma, but its approval in CRSwNP is limited to adults. We report a case of a 12-year- old boy with severe uncontrolled asthma and highly symptomatic CRSwNP referred to our center in May 2021. He was sensitized to house dust mite and pollens, and a specific immunotherapy had been tried previously. He was treated with high dose inhaled corticosteroid, long-acting beta agonist, long-acting muscarinic antagonist, montelukast and daily intra-nasal corticosteroids. Furthermore, a bilateral endoscopic sinus surgery with polypectomy was performed in April 2021. Despite adherence to medication and surgical treatment, both diseases were uncontrolled with frequent exacerbations requiring unscheduled visits and multiple systemic corticosteroid courses. This led to failure to thrive and several missed school days. Oral corticosteroid (OCS) tapering was unachieved due to symptoms rebound and so maintenance therapy with prednisolone 10mg daily was attempted, with only a slight improvement. High levels of eosinophils (1010 cells/muL), FeNO (122 ppb) and IgE (2255 kU/L) were present. Treatment with subcutaneous dupilumab was started in July 2021. A clinical and analytical improvement was evident at the 3-month evaluation (Table 1). He was able to stop prednisolone, and no clinically relevant exacerbations occurred. He also was fully vaccinated and had an asymptomatic COVID-19 infection in December 2021. Patients with CRSwNP and comorbid asthma have a higher disease burden than patients with each disease alone. In this adolescent, dupilumab was effective as an add-on treatment, for both severe asthma and CRSwNP. It led to disease control, OCS withdrawal, reduced eosinophilic inflammation, improved lung function, smell recovery and absence of exacerbations during follow-up. Dupilumab, targeting the type 2 inflammatory process, may allow a better management of pediatric patients >=12 years old with severe CRSwNP and comorbid asthma. (Table Presented).

Reduced COVID-19 vaccine response in patient treated with Dupilumab for IgG4 related disease

Case report: Dupilumab is a novel anti-interleukin- 4 (IL-4) receptor-alpha monoclonal antibody that targets the signaling pathways of IL-4 and IL-13, which are key type 2 cytokines. Current evidence suggests that patients on dupilumab are not at significantly increased risk of SARS-CoV- 2 related hospitalization and mortality and clinicians should avoid preventive cessation of therapy in patients with moderate-to- severe disease necessitating systemic treatment with dupilumab. However, there has been limited data about adequate and durable humoral immune response after vaccination to SARS-CoV- 2 in these patients, with some recent evidence by Runnstrom et al. suggesting that patients with severe asthma or atopic dermatitis on biologic therapies have lower antibody levels after SARS-CoV- 2 mRNA vaccination compared to healthy adults. We previously reported the case of a 71-year- old man with IgG4 related-disease (IgG4-RD) that we successfully treated with dupilumab. This patient was followed over the past three-years while his IgG4-RD remained well controlled on dupilumab which he remained on during the pandemic. Based on the vaccination guidelines and availability, he received two SARS-CoV- 2 mRNA vaccinations on March 24, 2021 and June 18, 2021. On July 24, 2021 (36 days after his last vaccination), during his routine follow up assessment, he was found to have no antibodies against SARS-CoV2. In response to this, we facilitated for him to receive his third booster vaccination on November 10, 2021. In preparation for this, his dupilumab was held for 1 month prior to this date and was continued two weeks after the injection. On December 3, 2021 (23 days after), his SARS-CoV2 Spike Total AB was repeated and found to be elevated at 2282 while his SARS-CoV2 NPROT Total AB was negative, implying immune response through vaccination and not natural exposure. To our knowledge, this is the first case report on a patient with IgG4-RD controlled on dupilumab who was found to have adequate vaccine titres after his dupilumab was held for 1 month after failing to mount a response to the first two vaccination doses while on therapy. As there is evidence that lower vaccine-specific titers afford less protection against COVID-19, acknowledging that holding dupilumab may not be feasible in all cases, this report highlights this approach as one possible strategy to protecting these individuals who may unknowingly remain at high risk for severe disease.

The use of biologics during the COVID 19 pandemic: Data of an allergy unit of a tertiary hospital in Greece

Background: The use of biologics during the pandemic has raised concerns throughout the scientific community. The current guidelines suggest continuing the use of biologics during the pandemic, while the initiation or continuation of treatment in case of symptomatic disease are remaining controversial unanswered questions. As a result the purpose of this study was to determine the frequency of symptomatic COVID19 infection in patients treated with biologic agents in an Allergy Unit of a University Hospital during the pandemic. Method(s): Patients of the Allergy Unit "D Kalogeromitros", who due to asthma, atopic dermatitis, Chronic Spontaneous Urticaria(CSU) or Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)were under treatment with biologic agents were included in the present study. Treatment of at least 2 months until the 31/12/2021 was necessary for a patient to be included in the present study. Result(s): A total of 77 patients [46 (59.7%) women, mean age 48.2 (range 15-82) years were included. The mean duration of treatment with biologics was 34.9 months (SD: +/-37 months). Overall, 83.1% (64/77) of patients were receiving omalizumab for asthma and CSU [13/64 (20.3%) and 51/64 (79.6%) respectively] while 9.1% (7/77) were receiving dupilumab for atopic dermatitis (4/7) and CRSwNP [4/7 (57.1%) and 3/7 (42.8%) respectively]. In addition, 5/77 (6.5%) and 1/77 (1.2%) were under treatment with mepolizumab and one with benralizumab respectively, due to severe uncontrolled asthma. A total of 6 patients with chronic spontaneous urticaria and 2/19 patients with asthma (1/5 with mepolizumab and 1/13 with omalizumab) had symptomatic COVID 19 infection as confirmed with a positive Polymerase Chain Reaction or Rapid Test. None of the patients treated with benralizumab or dupilumab had symptomatic COVID19 infection. Overall, 8/77 (10.3%) of patients had symptomatic SARS-CoV2 infection during the above period, a rate similar to the onein the same period identified in the general Greek population (11.2%). All patients had mild symptoms during the disease course with no patient admission to hospital. Conclusion(s): The frequency of symptomatic COVID19 infection identified in a population of Greek patients treated with biologic agents was no higher than than the one in the general Greek population. Furthermore, all patients had a mild course of the disease with no admissions, indicating that the use of biologics is a safe choice and can be continued during the pandemic.

Dupilumab efficacy and safety up to 52 weeks in adult and adolescent patients with eosinophilic esophagitis: Results from parts B and C of the randomized, placebo-controlled, three-part, phase 3 LIBERTY EoE TREET Study

Introduction (contexte de la recherche): In Parts A and B of the 3-part phase 3 LIBERTY EoE TREET study (NCT03633617), dupilumab 300 mg weekly (DPL qw) vs. placebo (PBO) demonstrated significant efficacy and acceptable safety up to 24 weeks (wks) in adults and adolescents with eosinophilic esophagitis (EoE). For patients (pts) who completed Parts A or B, Part C was an extended active treatment period for 28 wks. Objectif: To assess the safety and efficacy of DPL in pts who completed Part B and continued to Part C, up to 52 wks. Methodes: Of 80 DPL qw pts in Part B, 74 continued DPL qw in Part C (DPL/DPL). Of 79 PBO pts in Part B, 37 pts received DPL qw in Part C (PBO/DPL). Part B co-primary endpoints were proportion of pts achieving peak esophageal intraepithelial eosinophil (eos) count <= 6 eos/high power field (hpf) and absolute change from Part B baseline (BL) in Dysphagia Symptom Score (DSQ) score at Wk 24. Secondary endpoints included peak eos count, EREFS, and HSS grade and stage scores. In Part C, all co-primary and secondary endpoints were assessed at Wk 52 as secondary endpoints. Safety was also assessed. Resultats: Part B BL characteristics were similar across groups. At Wk 52 of Part C, 84.6% of DPL/DPL and 67.6% of PBO/DPL groups achieved peak eos count of <= 6 eos/hpf and mean (SD) absolute change from Part B BL in DSQ score was -30.26 (15.39) for DPL/DPL and -27.25 (11.46) for PBO/DPL pts. At Wk 52, peak eos count, EREFS, HSS grade and stage scores were reduced, compared with Part B BL, and EDP and T2 NESs were suppressed in DPL/DPL and PBO/DPL groups. Dupilumab demonstrated an acceptable safety profile in Part C;the most common (occurring >= 10%) treatment-emergent adverse events in DPL/DPL and PBO/DPL groups were injection-site reactions (13.5% and 10.8%), COVID-19 (9.5% and 10.8%) and nasopharyngitis (4.1% and 10.8%). Conclusion(s): As observed in Part A/C, dupilumab qw demonstrated persistent improvements in clinical, symptomatic, histologic, endoscopic and molecular features of EoE up to 52 wks and had an acceptable safety profile. PBO pts from Part B who received dupilumab in Part C showed similar efficacy to dupilumab qw pts of Part B.Copyright © 2023

Real-world response to dupilumab in patients with atopic dermatitis: a retrospective review of 100 patients

Dupilumab is a monoclonal antibody approved by the National Institute for Health and Care Excellence for the treatment of moderate-to-severe atopic dermatitis (AD) in 2018. It is indicated for patients who have not responded to at least one systemic medication or in whom these are contraindicated or not tolerated. Response criteria to allow continued treatment include at least a 50% reduction of Eczema Area and Severity Score (EASI) and/or at least a 4-point reduction in the Dermatology Life Quality Index (DLQI) score. Phase III clinical trials of dupilumab in AD reported a 75% reduction in EASI (EASI 75) of 51% in SOLO1 and 44% in SOLO2. Real clinic responses may differ from trials so we performed a retrospective review of 100 patients between June and August 2020 who had received dupilumab (44% female, 56% male;mean age 41 years). Fifty-eight per cent had a recorded diagnosis of asthma and 39% had a recorded diagnosis of allergic rhinitis. Seventy-six per cent of patients had received previous phototherapy. Ninety-seven per cent of patients received at least one systemic medication prior to commencing dupilumab. Thirty per cent (n = 29) received one, 33% (n = 32) received two, 33% (n = 32) received three and 4% (n = 4) received four prior to starting dupilumab. The most common were methotrexate (61%), followed by ciclosporin (22%) azathioprine (16%) and alitretinoin (1%). EASI scores were documented at baseline. The target time for EASI response assessment was 16 weeks, but we included outcome data recorded between 8 and 16 weeks, using the score nearest to 16 weeks where multiple scores were available. Seventy-five patients had response data recorded, 18 had stopped dupilumab and seven had missing data. Outcomes were 50% reduction in EASI [EASI 50;84% (n = 62)], EASI 75 [61% (n = 45)] and a 90% reduction in EASI [EASI 90;35% (n = 26)]. Mean (SE) EASI score pretreatment was 22 2 (1 2);at 16 weeks it was 5 8 (0 9). Sixty-five per cent of patients had a documented DLQI score at 8 and/or 16 weeks. Mean (SE) DLQI scores were 17 5 (0 7) predupilumab, 5 5 (1 1) at 8 weeks and 3 7 (0 8) at 16 weeks. Mean reduction was 13 8 (1 0). Eighty-six per cent (n = 56) had a reduction of four or more. Fifty-nine per cent of patients had Patient-Oriented Eczema Measure scores recorded. Mean (SE) values were 22 5 (0 5) predupilumab, 6 2 (1 2) at 8 weeks and 7 1 (1 1) at 16 weeks. Mean reduction was 15 4 (1 0). Compared with prospective clinical trials, real-world data have the limitations of missing data and slight scoring date variations, including the impact of the COVID-19 pandemic on missed appointments. Sixteen-week outcome data are not available for patients who withdrew from treatment. However, for the 75 patients with outcome data the proportion achieving EASI 75 and a 4-point reduction in DLQI is encouraging and similar to data from phase III trials.

Biological documentation in primary care: a review from the dermatology department of a Welsh hospital

Biological therapies are increasingly being used in dermatology to treat conditions such as psoriasis and eczema. These medications are prescribed and dispensed in secondary care;however, it is important that they are present in the patient's primary care record, as this is often used by both the primary care provider and the hospital clerking doctor when the patient presents with other health concerns. Biologics are immunosuppressive medications, and it is thus important that any practitioner treating a patient who has been prescribed them is aware of this. Using a departmental record, all patients prescribed biological therapies or subcutaneous methotrexate were identified (n = 157). Their primary care medication record was then interrogated to assess whether the biological therapy was recorded. Forty-five (29%) patients on biological therapies or subcutaneous methotrexate did not have this recorded on their general practitioner (GP) record. The most common medications not recorded were ustekinumab (n = 14) and dupilumab (n = 13). There was no clear pattern indicating that a particular GP surgery was recording these medications poorly, and the patients were cared for evenly between the dermatology consultants in the department. This brief piece of work demonstrates that there is a problem with these prescriptions being accurately recorded on the GP record. Almost one-third of patients in the department did not have their biological therapy listed on their primary care record. Practitioners must be aware that a patient is on an immunosuppressive medication, especially when diagnosing and treating infections and assessing patient priority for COVID-19 vaccination, as well as including the need to avoid live vaccines. Furthermore, the GP record was used by Welsh Government agencies to identify patients needing to shield during the COVID-19 pandemic. These 45 patients recognized in the study would not necessarily have been identified as potentially high risk (depending on other comorbidities) and may therefore not have been advised to shield (in line with British Association of Dermatologists guidance for self-isolation and immunosuppressed patients). To rectify this problem in the short term, each GP surgery was contacted regarding the particular patients identified and were advised to add their biological therapy to their primary care record. Discussions between primary and secondary care and pharmacy are ongoing in order to identify how to prevent this problem from continuing.

Improvement of eosinophilic chronic rhinosinusitis after infection with severe acute respiratory syndrome corona virus 2 during dupilumab therapy: A case report.

Eosinophilic chronic rhinosinusitis (ECRS) is an intractable type 2 inflammatory disease of the paranasal sinuses that persists even after endoscopic sinus surgery (ESS) and systemic corticosteroid therapy. Dupilumab, a monoclonal antibody against the shared receptor components of interleukin (IL)-4 and IL-13, is a novel and effective treatment option for ECRS. Herein, an atypical case of ECRS that improved after infection with severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) during dupilumab therapy is reported. A 40-year-old man with a history of ESS for ECRS visited our hospital with complaints of nasal congestion and dysosmia. Nasal endoscopy revealed bilateral nasal polyps occupying the nasal cavity. Computed tomography (CT) revealed a soft tissue density lesion filling all sinuses on both sides. Based on these findings, ECRS recurrence was confirmed; however, 3 years of subsequent corticosteroid therapy did not improve disease activity. Accordingly, dupilumab therapy was initiated, although 6 months of therapy resulted in only slight improvement in ECRS. Eight months after the initiation of dupilumab therapy, the patient was infected with SARS-CoV-2; thereafter, he noticed an improvement in smell. Nasal endoscopy and sinus CT revealed a marked reduction in nasal polyps and soft tissue density lesions of the sinuses, respectively. With continued dupilumab therapy, no re-exacerbation of ECRS was confirmed at the 6-month follow-up from SARS-CoV-2 infection. Currently, there are no reports describing the impact of SARS-CoV-2 infection on ECRS. As such, careful follow-up and accumulation of cases are necessary.

Decreased Anxiety and Depression Scores in Adolescents with Asthma Receiving Dupilumab Therapy

Rationale: Since 2019, dupilumab has been used to treat severe asthma. Within the severe asthma population, prevalence of anxiety and depression is high. We hypothesize that initiation of dupilumab therapy in children is associated with subsequent reduction in anxiety and depression scores. Methods: Our retrospective study included 33 patients (age 11 to 18;55% female) receiving dupilumab therapy. 18 patients had GAD-7 and PHQ-9 scores available both pre- and post-initiation of dupilumab therapy and were included for analysis. The most recent GAD-7 and PHQ-9 scores prior to dupilumab initiation were compared to those at the first clinic visit after dupilumab initiation. Standard GAD-7 and PHQ-9 severity cutoff scores were used. Results: GAD-7 distribution pre-initiation (vs post-initiation): severe 16.7 % (0%), moderate 5.6% (5.6%), mild 11.1 % (33.3%), minimal 66.7% (61.1%). PHQ-9 distribution pre-initiation (vs post-initiation): severe 0% (0%), moderately severe 5.6 % (0%), moderate 11.1% (5.6%), mild 27.8 % (44.4%), minimal 55.6 % (50%). Change in severity distribution approached significance for both GAD-7 (p=0.08) and PHQ-9 (p=0.07). 9 of the 12 patients who were initiated on dupilumab after the start of the COVID-19 pandemic showed decrease in both GAD-7 and PHQ-9 scores;those results were not statistically significant. Conclusions: Despite our small sample size, our study demonstrates a downtrend in anxiety and depression scores amongst adolescents after initiation of dupilumab therapy. This is particularly notable given the complex psychosocial context of the study period, which included the onset of the COVID-19 pandemic.

Duodenal Stricture as a Rare, Possible Complication of Eosinophilic Gastrointestinal Disease (Egid)

EGID is a recently described condition with an unknown etiology and pathogenesis. There are three case reports of duodenal stricture associated with EGID: one in an adult requiring pancreaticoduodenectomy due to the suspicion of malignancy and 2 cases in a child and a young adult, who responded to oral steroids. We report the case of a 10-year-old who presented to A&E with a 9-month history of epigastric abdominal pain and 1 episode of haematemesis, on a background of asthma. He was treated for Helicobacter pylori, based on a positive stool antigen. Abdominal pain and vomiting persisted, therefore an oesophago-gastro-duodenoscopy (OGD) was performed. This identified widespread white plaques throughout the oesophagus, erythema and nodularity of the gastric antrum and white nodules in the first part of the duodenum. Histology revealed changes of EGID and eosinophilic oesophagitis (EOE) and patient was commenced on Montelukast, oral viscous Budesonide (OVB), Cetirizine and continued proton pump inhibitor (PPI). After the allergy workup identified house dust mites, cat sensitisation and fish allergy, a 6-food elimination diet was initiated. During the next 2 years, symptoms subsided, and endoscopy changes improved, with only mild signs of active EOE while on OVB, PPI and diary/egg/fish free diet. However, the patient relapsed due to poor compliance to treatment. He became more unwell during the Covid pandemic with recurrent vomiting and static weight. A trial of dupilumab was considered, however his reassessment OGD had to be delayed due to restricted access to theatre. He was treated empirically with a reducing course of oral prednisolone, with temporary response. The endoscopic assessment performed subsequently showed erythema, erosions and white plaques in the distal oesophagus and gastric antrum with narrowing between the first and the second part of the duodenum (D2), that could not be entered. Histology identified mild upper oesophagitis (4 eosinophils (eos)/HPF), active middle and lower oesophagitis (20 eos/HPF and 12 eos/HPF, respectively), chronic gastritis (80 eos/HPF) and nonspecific reactive changes of the proximal duodenum. A barium meal confirmed a duodenal stricture. At this stage, we recommended a sloppy diet and a second weaning course of oral prednisolone, along with Montelukast. He was subsequently commenced on azathioprine for maintenance of remission. A repeat barium study and small bowel MRI performed post course of steroids and on azathioprine revealed stable appearances of the proximal duodenal stricture, excluding the presence of further strictures. While the patient has responded to the course of oral steroids and azathioprine, a repeat upper GI endoscopy is currently planned to dilate the duodenal stricture. The challenges posed by this case were the rarity of the condition, limited treatment options and access to endoscopy during the Covid pandemic and the fact that unlike previous case reports a sustained remission could not be obtained on steroids, and a maintenance immunosuppressive medication was required. We can conclude that this subgroup of patients should be monitored closely for signs of bowel obstruction and will require more intense treatment, including immunomodulators, endoscopic dilatation and or surgery.

Effect of COVID-19 (SARS-CoV-2) Vaccination on Patients with Atopic Dermatitis Treated with Dupilumab: A Multicenter, Observational Study.

BACKGROUND: Atopic dermatitis (AD) patients usually wonder if their condition will worsen after vaccination or if they should continue with the treatment they are receiving. Considering that many patients treated with dupilumab had previously experienced severe AD symptoms and flares, the concerns are more understandable. OBJECTIVE: This study aimed to investigate the safety of the coronavirus disease 2019 (COVID-19) vaccination in patients with AD treated with dupilumab. METHODS: We enrolled 133 patients (101 dupilumab-treated and 32 systemic oral agents-treated as control group) with AD from six hospitals. Patients were asked about worsening pruritus and AD (5-point Likert scale) after vaccination. AD variables (eczema area and severity index [EASI], investigator's global assessment [IGA], itch numerical rating scale [NRS], sleep NRS, and patient-oriented eczema measure [POEM]) were compared pre- and post-vaccination. Adverse reactions to the COVID-19 vaccination were observed. RESULTS: The incidence of adverse reactions to COVID-19 vaccines and worsening AD symptoms in dupilumab-treated patients were not significantly different compared with that in the control group. The itch NRS score increased significantly after vaccination (p<0.001). However, there were no statistically significant differences between the pre-and post-EASI, IGA, and POEM scores. Eight patients (7.9%) had worse EASI scores and required rescue therapy; however, most were easily managed with low-dose steroids or topical agents. None of the patients discontinued dupilumab treatment. CONCLUSION: No serious adverse reactions were observed in patients with AD after COVID-19 vaccination. Exacerbation of pruritus and AD symptoms was observed but was mostly mild and transient.