Omalizumab and Churg-Strauss syndrome
Authors: Pedro Giavina-Bianchi, Mara Giavina-Bianchi, Rosana Agondi, Jorge Kalil
Journal: Journal of Allergy and Clinical Immunology (2008)

To the Editor: Ruppert at al1Ruppert A.M. Averous G. Stanciu D. Deroide N. Riehm S. Poindron V. et al.Development of Churg-Strauss syndrome with controlled asthma during omalizumab treatment.J Allergy Clin Immunol. 2008; 121: 253-254Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar described an interesting case of Churg-Strauss syndrome (CSS) occurring during omalizumab treatment. This is, as far as we know, the third publication in the literature to describe such an event.1Ruppert A.M. Averous G. Stanciu D. Deroide N. Riehm S. Poindron V. et al.Development of Churg-Strauss syndrome with controlled asthma during omalizumab treatment.J Allergy Clin Immunol. 2008; 121: 253-254Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 2Winchester D.E. Jacob A. Murphy T. Omalizumab for asthma.N Engl J Med. 2006; 355: 1281-1282Crossref PubMed Scopus (2) Google Scholar, 3Bargagli E. Rottoli P. Omalizumab treatment associated with Churg-Strauss vasculitis.Int Arch Allergy Immunol. 2007; 145: 268Crossref PubMed Scopus (19) Google Scholar Our case was different.4Giavina-Bianchi P. Giavina-Bianchi M. Agondi R. Kalil J. Three months' administration of anti-IgE to a patient with Churg-Strauss syndrome.J Allergy Clin Immunol. 2007; 119: 1279Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 5Giavina-Bianchi P. Giavina-Bianchi M. Agondi R. Kalil J. Administration of anti-IgE to a Churg-Strauss syndrome patient.Int Arch Allergy Immunol. 2007; 144: 155-158Crossref PubMed Scopus (47) Google Scholar We had a patient with CSS whose asthma was uncontrolled, and we administered anti-IgE to achieve asthma control. At present, our patient has been treated with anti-IgE for 1 year. He has well-controlled asthma, maintains a low eosinophil blood count, and has not presented an increase of CSS clinical activity.6Giavina-Bianchi P. Agondi R. Kalil J. One Year Administration of Anti-IgE to a Patient with Churg-Strauss Syndrome.Int Arch Allergy Immunol. 2008; 146: 176Crossref PubMed Scopus (14) Google Scholar Since omalizumab administration started, the patient has not taken systemic corticosteroids. We believe that CSS in the 3 described cases1Ruppert A.M. Averous G. Stanciu D. Deroide N. Riehm S. Poindron V. et al.Development of Churg-Strauss syndrome with controlled asthma during omalizumab treatment.J Allergy Clin Immunol. 2008; 121: 253-254Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 2Winchester D.E. Jacob A. Murphy T. Omalizumab for asthma.N Engl J Med. 2006; 355: 1281-1282Crossref PubMed Scopus (2) Google Scholar, 3Bargagli E. Rottoli P. Omalizumab treatment associated with Churg-Strauss vasculitis.Int Arch Allergy Immunol. 2007; 145: 268Crossref PubMed Scopus (19) Google Scholar is actually caused by systemic steroid tapering rather than anti-IgE use. The patient of Ruppert et al1Ruppert A.M. Averous G. Stanciu D. Deroide N. Riehm S. Poindron V. et al.Development of Churg-Strauss syndrome with controlled asthma during omalizumab treatment.J Allergy Clin Immunol. 2008; 121: 253-254Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar stopped prednisolone and had a rapid and dramatic reduction of fluticasone before CSS diagnosis. It would be interesting to review the patient history for signs of CSS, including increased eosinophil blood count. Bargagli and Rottoli,3Bargagli E. Rottoli P. Omalizumab treatment associated with Churg-Strauss vasculitis.Int Arch Allergy Immunol. 2007; 145: 268Crossref PubMed Scopus (19) Google Scholar encouraged by our case, continued to administer omalizumab to their patient along with CSS treatment with systemic corticosteroids and had a good outcome. This is a discussion similar to the one about the use of antileukotriene drugs in asthma. Although the immunopathogenesis of CSS is still poorly known, it is difficult to conjecture that it can be induced or amplified by anti-IgE effects. Our case and that of Bargagli and Rottoli3Bargagli E. Rottoli P. Omalizumab treatment associated with Churg-Strauss vasculitis.Int Arch Allergy Immunol. 2007; 145: 268Crossref PubMed Scopus (19) Google Scholar strengthen this idea. All these cases together suggest that you can use omalizumab in patients with CSS to treat and control asthma, but it was also demonstrated that anti-IgE does not control CSS activity. Systemic corticosteroids are the drug of choice to treat CSS, and its tapering in asthmatic patients has to be made with caution, especially when CSS is suspected. Nevertheless, large and long-term studies would be appropriate before widespread use of omalizumab in patients with asthma and CSS.