PG 2025: Pulmonary Literature Review and Interactive Complex Case Presentations (PG)-Rogers

Rogers - CHEST2025YIR casesfin

Pdf Summary

This 2025 pulmonary literature review by Dr. Linda Rogers discusses complex asthma cases focusing on biologic treatments, refractory asthma evaluation, and comorbidities including immunodeficiency.<br /><br />Case 1 presents a 32-year-old woman with severe asthma uncontrolled despite high-dose inhaled corticosteroids (ICS) and long-acting beta-agonists (LABA), frequent oral steroid bursts, obesity (BMI 35), elevated biomarkers (FeNO 95 ppb, eosinophils 400/µL, IgE 200), and multiple perennial allergen sensitizations. The review highlights criteria for biologic initiation, emphasizing biomarker dominance (eosinophils, FeNO, IgE) and clinical context like chronic rhinosinusitis with nasal polyposis, atopic dermatitis, oral corticosteroid dependence, food anaphylaxis, and reproductive status. Patient factors such as payor restrictions, injection preferences, travel, and psychosocial issues influence biologic choice. Biologics are selected by biomarker profiles: anti-IL5/5R for eosinophil dominant, anti-IL4R for FeNO dominant or atopic dermatitis, anti-IgE for allergic phenotypes, and anti-TSLP for low biomarkers. Follow-up showed clinical improvement but residual symptoms related to obesity, obstructive sleep apnea, and GERD.<br /><br />Case 2 details a 62-year-old with steroid-dependent asthma poorly controlled by multiple biologics, complicated by diagnosis-specific antibody deficiency (immunodeficiency) and tracheomalacia. She was treated with IV immunoglobulin and azithromycin, with improved clinical status, steroid taper, and substantial weight loss on GLP-1 agonist therapy. This case illustrates the importance of considering inborn errors of immunity (IEI) in adults with atypical asthma, recurrent infections, or autoimmune features. Diagnostic work-up includes immunoglobulin levels, vaccine response, lymphocyte flow cytometry, chest imaging, bronchoscopic evaluation, and potential genetic testing.<br /><br />Key points stress comprehensive asthma history, including steroid burden and comorbidities; extensive testing to identify refractory causes; awareness that symptoms can be misleading; and that personalized biologic therapy and immunologic evaluation improve outcomes in complex asthma patients.

Keywords

pulmonary literature review

complex asthma cases

biologic treatments

refractory asthma evaluation

immunodeficiency

biomarkers in asthma

severe asthma management

comorbidities in asthma

inborn errors of immunity

personalized asthma therapy