Vasospasm due to eosinophilic coronary periarteritis treated with an anti-IL-5

ABSTRACT

Background: Vasospasm due to eosinophilic coronary periarteritis (VECP) can cause not only vasospastic angina but also myocardial infarction and sudden cardiac death. It is usually resistant to conventional treatment of coronary disease and responds to systemic corticosteroids. The role that may have the monoclonal antibodies reducers eosinophils is unknown. Method: A 52-year-old female with chronic rhinosinusitis with nasal polyposis, moderate persistent bronchial asthma and Aspirinexacerbated respiratory disease(AERD), without atopy, had been treated with inhaled and intranasal fluticasone, oral montelukast and inhaled formoterol. In July 2019, she arrived at the emergency room with an acute coronary syndrome. Results: The procedures performed revealed high levels of troponin 16717ng/L(0- 47ng/L), and abnormal electrocardiogram (alteration of repolarization in II, III and aVF). Marked eosinophilia of 750cells/ mm3 was noticed. She was treated with oral vasodilators and aspirin, which due to her AERD required rapid desensitization, being effective. However, she continued with recurrent chest pain and electrocardiographic abnormalities. Diagnostic coronary angiography revealed vasospasm in the right coronary artery without atheromatous lesions. Type 2 myocardial infarction secondary to VECP was suspected and prednisone 30mg/day was started with complete resolution of chest pain. She developed a Cushing syndrome and prednisone dose was reduced, but chest pain and eosinophilia(1000/mm3) reappeared, and prednisone 20mg/day was reintroduced. It was decided to discontinue corticosteroids and treatment was begun with anti-IL-5(benralizumab) in May 2020, reducing eosinophilia( 0/mm3) from the first dose. At 6 months we suspended prednisone without new episodes of pain. In August 2020, she was visited due to SARS-CoV-2 infection without symptoms of bronchospasm or pneumonia and received the 4th dose of benralizumab without complications. Conclusion: An acute coronary syndrome refractory to conventional medications with normal coronary arteries and eosinophilia, with a history of chronic rhinosinusitis/polyposis, asthma and/or AERD, VECP should be considered and early treatment with corticosteroids could save lives. This is the first case to our knowledge in which anti IL 5 has been used for VECP to control of the eosinophilic disorder. Likewise, it was administrated during the SARS-CoV-2 infection without complications.