Abstract Introduction Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare eosinophilic small-vessel vasculitis characterized by asthma and sinonasal disease. Pulmonary infiltrates are typical while fixed airway dilation is uncommon. We report a case of bronchiectasis attributable to EGPA in an older adult with a history of long-standing allergic asthma. Case Report A 72-year-old man with lifelong allergic asthma and chronic rhinitis presented with one year of progressive cough, wheeze, and mucoid sputum after hospitalization in April 2024 for pneumonia. He denied hemoptysis, fever, weight loss, neuropathy, rash, or renal symptoms. Chest computed tomography (CT) demonstrated lower-lobe-predominant bronchiectasis with mucoid impaction, ground-glass opacities, and tree-in-bud nodules. Pulmonary function testing showed preserved physiology despite radiographic airway disease. Work-up for bronchiectasis revealed positive anti-neutrophil cytoplasmic antibody (ANCA) with myeloperoxidase (MPO) specificity (6.6), antinuclear antibody 1:160, borderline positive rheumatoid factor, and negative anti-proteinase-3. Immunoglobulin G, M, and A were normal; immunoglobulin E was elevated. Allergic bronchopulmonary aspergillosis was excluded (negative Aspergillus fumigatus/niger immunoglobulin E and immunoglobulin G), aspiration was excluded (normal barium swallow), and acid-fast bacilli and bacterial cultures were negative. Airway clearance with nebulized albuterol and three percent hypertonic saline improved sputum burden. Omalizumab was transitioned to dupilumab for improved asthma control with symptomatic improvement. However, with multidisciplinary consensus for probable EGPA without renal or neurologic involvement, therapy was subsequently switched to mepolizumab at EGPA dosing. Discussion Bronchiectasis from EGPA is rarely described and may be incorrectly attributed to postinfectious disease or aspiration.1–3 In this patient, characteristic CT abnormalities, exclusion of competing etiologies, and MPO-ANCA positivity in the setting of long-standing asthma supported EGPA as the unifying diagnosis. Recognition redirected management from repetitive antibiotics to structured airway clearance and targeted biologic therapy. This case highlights that unexplained bronchiectasis in adults with chronic asthma warrants autoimmune evaluation and that early identification of EGPA may prevent irreversible airway remodeling and optimize outcomes. References 1. Cloé Comarmond et al., “Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss): Clinical Characteristics and Long-term Followup of the 383 Patients Enrolled in the French Vasculitis Study Group Cohort,” Arthritis & Rheumatism 65, no. 1 (2013): 270-81, https://doi.org/10.1002/art.37721. 2. A. Vaglio et al., “Eosinophilic Granulomatosis with Polyangiitis ( C Hurg- S Trauss): State of the Art,” Allergy 68, no. 3 (2013): 261-73, https://doi.org/10.1111/all.12088. 3. Thomas Barba et al., “Diffuse Bronchiectasis and Airflow Obstruction in Granulomatosis with Polyangiitis,” Sarcoidosis Vasculitis and Diffuse Lung Disease 35, no. 1 (2018): 81-84, https://doi.org/10.36141/svdld.v35i1.6298. This abstract is funded by: None
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