case_images: PMC10787210_01
case_images: Treatment and clinical course.. The patient initially received OCS and additional IVIG therapy. The amplitude and extent of sensory impairment in the lower extremities remained unresolved. This impairment mostly disappeared after the initiation of mepolizumab. The MRC grade of movement disturbance in the lower extremities improved after starting OCS and mepolizumab.. OCS: oral corticosteroid; IVIG: intravenous immunoglobulin; MRC: Medical Research Council.
case_images: cureus-0016-00000052192-i01.jpg
case_images: PMC10787210_01_cureus-0016-00000052192-i01.jpg
case_images: FIG1
case_images: He had hypoesthesia in his legs and bilateral ankle dorsiflexion disturbance (Medical Research Council (MRC) grade 2; 0 (no contraction) to 5 (normal power)) (Figure 1). After intravenous immunoglobulin (IVIG) administration, ankle dorsiflexion deterioration improved (Figure 1). Contrary to the improvement in his laboratory data, he experienced persistent hypoesthesia and paresthesia in the legs during the course of the study (Figure 1). Deteriorations in ankle dorsiflexion were also resolved (Figure 1).
case_images: Chest CT. The CT scan reveals a cavity and pleural thickening of the right upper lung on day 1 (a), the disappearance of pleural thickening and residual cavity with a fungus ball lesion one month after receiving OCS (b), fungus ball lesion progression of the right lung while tapering OCS (c), and collapsed fungus ball lesion during mepolizumab administration (d).. CT: computed tomography; OCS: oral corticosteroids.
case_images: cureus-0016-00000052192-i02.jpg
case_images: PMC10787210_01_cureus-0016-00000052192-i02.jpg
case_images: FIG2
case_images: Chest computed tomography (CT) revealed a cavity with a thickened wall in the right upper lobes and right pleural thickness on day 1 (Figure 2a). Meanwhile, dense shadows around the cavity in the right upper lobe were reduced, but a nodule inside the cavity remained on chest CT (Figure 2b). CT after nine months despite continuous treatment with itraconazole (Figure 2c). Considering the additive effect of OCS on peripheral neuropathy and the involvement of OCS in progressive CPA, 100 mg of subcutaneous mepolizumab every four weeks was initiated; this dose was approved for severe asthma but not EGPA because mepolizumab was not approved for EGPA at that time in Japan. In addition, the fungus ball sign collapsed in the right upper lesion on chest CT (Figure 2d), and the serum Aspergillus galactomannan antigen level was normalized.
case_images: Nerve conduction study changes. CMAP (a) and MNCV (b) in tibial nerves and SNAP (c) and SNCV (d) in sural nerves improved during OCS, IVIG, and Mepo. therapy. Closed circle: left nerve; open square: right nerve.. CMAP: compound motor action potential; MNCV: motor nerve conduction velocity; SNAP: sensory nerve action potential; SNCV: sensory nerve conduction velocity; OCS: oral corticosteroid; IVIG: intravenous immunoglobulin; Mepo.: mepolizumab.
case_images: cureus-0016-00000052192-i03.jpg
case_images: PMC10787210_01_cureus-0016-00000052192-i03.jpg
case_images: FIG3
case_images: A nerve conduction study (NCS) revealed a modest reduction in the compound motor action potential (CMAP; reference range: 5.0-21.4 mV) and a marginal reduction in the motor nerve conduction velocity (MNCV; 41-55 m/s) in the bilateral tibial nerves, along with a modest decrease in the sensory nerve action potential (SNAP; 3.1-15.1 microV) and a marginal decline in the sensory nerve conduction velocity (42.7-51.7 m/s) in the sural nerve (Figure 3a-d). However, sensory symptoms remained severe, and CMAP, MNCV, and SNAP rapidly deteriorated (Figure 3a-c). MNCV to the reference range and a modest improvement of SNAP 27 months after starting mepolizumab (Figure 3a-c). Most of the neurological symptoms were resolved one year after the induction of mepolizumab.