Allergic bronchopulmonary aspergillosis (ABPA) is common in cystic fibrosis (CF). Treatment is challenging and the relapse rate is high. Standard therapy is oral steroids and antifungals. However, long‐term systemic steroid often results in adverse effects and drug interactions between azoles and CFTR modulators are a potential concern. Mepolizumab, an anti‐interleukin (IL)‐5 monoclonal antibody, can benefit patients with severe eosinophilic asthma and there are reports of mepolizumab use in ABPA but not in ABPA complicating CF. We present the case of an adult with CF who had recurrent ABPA and intolerable treatment side effects with steroid, azole, and omalizumab. Mepolizumab was well tolerated and led to significantly improved clinical stability and symptomatic improvement. To our knowledge, this is the first report of successful mepolizumab treatment for ABPA in CF. Mepolizumab may be an important adjunctive treatment for difficult to control ABPA in CF.
Indwelling pleural catheters (IPCs) are effective management options for malignant pleural effusion. Symptomatic fluid loculation is a recognized complication of IPC use and is usually managed with intrapleural instillation of fibrinolytic drugs, such as tissue plasminogen activator (tPA). A previous multicentre observational study showed significant heterogeneity among centres in their dosing regimen for tPA (from 2 to 20 mg) in treating symptomatic loculations. Potential pleural bleeding, especially in high‐risk patients, often deters clinicians from initiating intrapleural fibrinolytic therapy. Lower doses of tPA may reduce bleeding risks. This case report describes the successful use of 0.5 mg (the lowest reported dose) of tPA in a patient with significant bleeding risks whose IPC was complicated by symptomatic loculation.
Indwelling pleural catheter is an established management for malignant pleural effusions. Extending its use to patients with malignant ascites by insertion of a catheter intraperitoneally enables regular outpatient drainage and improves quality‐of‐life. However, indwelling pleural/peritoneal catheter (IPC/IPeC) is associated with catheter‐related infections, traditionally managed with systemic antibiotics and occasionally requires catheter removal. Direct administration of antibiotics intra‐abdominally via peritoneal dialysis (PD) catheters is a well‐established, efficacious practice in PD‐related peritonitis and minimizes systemic adverse effects. We applied the same principles to a patient with peritoneal mesothelioma who developed peritonitis 3 weeks after insertion of IPeC. Intraperitoneal vancomycin was administered via, and compatible with, the IPeC. The patient tolerated the treatment without adverse effects and made a full recovery without requiring catheter removal.
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