Successful Use of Dupilumab as a Salvage Therapy for Recalcitrant Allergic Fungal Rhinosinusitis: A Case Report.

Allergic fungal rhinosinusitis (AFRS) is a subtype of chronic rhinosinusitis with nasal polyps (CRSwNP) which is distinguished by the presence of eosinophilic mucin, type 1 hypersensitivity reaction resulting from fungi residing within the sinus, and characteristic imaging findings of the paranasal sinuses. Surgical intervention, sinonasal irrigations, and topical and systemic medications are commonly used to reduce the fungal load and antigenic stimulation. Despite the advancement of medical and surgical management of AFRS, a high recurrence rate is still a significant concern. The proper treatment for refractory AFRS remains controversial. Herein, we discuss the use of dupilumab for controlling refractory AFRS. We report a case of a 33-year-old female patient known to have had AFRS for 16 years. Due to the recurring nature of her illness, 16 functional endoscopic sinus surgeries (FESS) have been done to control her symptoms. The last operation was done in our institution; evidence for cure was insufficient with the persistence of symptoms. After a consensus decision with the multidisciplinary management team, she was an appropriate candidate for therapy with dupilumab. After six months of using the medication, magnificent improvement and control of symptoms were noted, and post-treatment CT scans illustrated excellent progression from previous scans. AFRS could be an extremely debilitating disease with significant impairment of quality of life even when standard therapy and extensive surgical interventions are implemented. Dupilumab can be an excellent option as a salvage therapy for recalcitrant AFRS with significant improvement in patients' quality of life and resolution of symptoms.