Transl Clin Pharmacol.  2018 Jun;26(2):60-63. 10.12793/tcp.2018.26.2.60.

Successful additional clarithromycin and tacrolimus treatment for hypereosinophilia associated with eosinophilic granulomatosis with polyangiitis

• Ohe M
• Shida H
• Horita T
• Furuya K

• KMID: 2413828
• DOI: http://doi.org/10.12793/tcp.2018.26.2.60

Abstract

A 41-year-old man suffering from eosinophilic granulomatosis with polyangiitis (EPGA), diagnosed at another clinic on the basis of American College of Rheumatology Criteria, with a history of bronchial asthma, eosinophilia, mononeuritis multiplex, and non-fixed pulmonary infiltrates, was admitted to our department for further treatment. The patient complained of chest pain that started recently. An echocardiogram identified myocardial thickening and decreased wall motion, based on which the patient was diagnosed as having EPGA with myocarditis. The patient was successfully treated using glucocorticoids, such as methyl prednisolone (PSL) and PSL in combination with cyclophosphamide (CPM). However, CPM administration was discontinued afterwards because of the risk of bone marrow toxicity, the increased eosinophilic count (EOC) that we considered as an index of disease activity. Subsequently, the patient received additional clarithromycin (CAM) and tacrolimus (TAC) treatment considering their immunomodulatory effects. As a result, the EOC decreased and the PSL dosage could be reduced. This case shows that additional CAM and TAC treatment may be beneficial in some cases of EPGA.

Keyword

Churg-Strauss; Clarithromycin; Cyclophosphamide; Prednisolone; Syndrome; Tacrolimus

MeSH Terms

Adult
Asthma
Bone Marrow
Chest Pain
Clarithromycin*
Cyclophosphamide
Eosinophilia
Eosinophils*
Glucocorticoids
Granulomatosis with Polyangiitis*
Humans
Mononeuropathies
Myocarditis
Prednisolone
Rheumatology
Tacrolimus*
Clarithromycin
Cyclophosphamide
Glucocorticoids
Prednisolone
Tacrolimus

Figure

• 

  Figure 1 (A) A chest roentgenogram shows infiltration shadows in bilateral upper lung fields and right lower lung field. (B) A chest roentgenogram shows improvement in infiltration shadows.

Reference

1. Grayson PC, Monach PA, Pagnoux C, Cuthbertson D, Carette S, Hoffman GS, et al. Value of commonly measured laboratory tests as biomarkers of disease activity and predictors of relapse in eosinophilic granulomatosis with polyangiitis. Rheumatology (Oxford). 2015; 54:1351–1359. DOI: 10.1093/rheumatology/keu427. PMID: 25406357.

2. Wechsler ME, Akuthota P, Jayne D, Khoury P, Klion A, Langford CA, et al. Mepolizumab or placebo for eosinophilic granulomatosis with polyangiitis. N Engl J Med. 2017; 376:1921–1932. DOI: 10.1056/NEJMoa1702079. PMID: 28514601.

3. Fajt ML, Wenzel SE. Development of new therapies for severe asthma. Allergy Asthma Immunol Res. 2017; 9:3–14. DOI: 10.4168/aair.2017.9.1.3. PMID: 27826957.

4. Adachi T, Motojima S, Hirata A, Fukuda T, Kihara N, Kosaku A, et al. Eosinophil apoptosis caused by theophylline, glucocorticoids, and macrolides after stimulation with IL-5. J Allergy Clin Immunol. 1996; 98:S207–S215. PMID: 8977529.

5. Wu L, Zhang W, Tian L, Bao K, Li P, Lin J. Immunomodulatory effects of erythromycin and its derivatives on human T-lymphocyte in vitro. Immunopharmacol Immunotoxicol. 2007; 29:587–596. PMID: 18075867.

6. Mori A, Kaminuma O, Ogawa K, Nakata A, Egan RW, Akiyama K, et al. Control of IL-5 production by human helper T cells as a treatment for eosinophilic inflammation: comparison of in vitro and in vivo effects between selective and non selective cytokine synthesis inhibitors. J Allergy Clin Immunol. 2000; 106:S58–S64. PMID: 10887335.

7. Hossain M, Okubo Y, Sekiguchi M. Effects of various drugs (staurosporine, herbimycin A, ketotifen, theophylline, FK506 and cyclosporine A) on eosinophil viability. Arerugi. 1994; 43:711–717. PMID: 7520689.

8. Vafadari R, Kraaijeveld R, Weimar W, Baan CC. Tacrolimus inhibits NF-κB activation in peripheral human T cells. PLoS One. 2013; 8:e60784. DOI: 10.1371/journal.pone.0060784. PMID: 23573283.

9. Masi AT, Hunder GG, Lie JT, Michel BA, Bloch DA, Arend WP, et al. The American College of Rheumatology 1990 criteria for the classification of Churg-Strauss syndrome. Arthritis Rheum. 1990; 33:1094–1100. PMID: 2202307.

10. Papadimitraki ED, Moyssakis I, Mavrogeni S, Mylona M, Anagnostou D, Merkouris K, et al. A Churg-Strauss syndrome patient with myocardial involvement. J Cardiol Cases. 2015; 11:52–55. PMID: 30534258.

11. Comarmond C, Pagnoux C, Khellaf M, Cordier JF, Hamidou M, Viallard JF, et al. Eosinophilic granulomatosis with polyangiitis (Churg–Strauss): clinical characteristics and long-term follow up of the 383 patients enrolled in the French Vasculitis Study Group cohort. Arthritis Rheum. 2013; 65:270–281. PMID: 23044708.

12. Ohe M, Hashino S. Successful treatment of eosinophilic gastroenteritis with clarithromycin. Korean J Intern Med. 2012; 27:451–454. DOI: 10.3904/kjim.2012.27.4.451. PMID: 23269887.

13. Phaw NA, Tsai HH. Eosinophilic gastroenteritis: a challenge to diagnose and treat. BMJ Case Rep. 2016; 2016:bcr2016215964. DOI: 10.1136/bcr-2016-215964.

14. Amayasu H, Yoshida S, Ebana S, YamamotoY , Nishikawa T, Shoji T, et al. Clarithromycin sup-presses bronchial hyperresponsiveness associated with eosinophilic inflammation in patients with asthma. Ann Allergy Asthma Immunol. 2000; 84:594–598. PMID: 10875487.

15. Niiyama S, Amoh Y, Suzuki K, Wada T, Katsuoka K. Efficacy of tacrolimus against Churg-Strauss syndrome in a patient with myasthenia gravis. Rheumatol Int. 2010; 30:847–848. DOI: 10.1007/s00296-009-1039-8. PMID: 19582460.

16. Watanabe S, Aizawa-Yashiro T, Tsuruga K, Takahashi T, Ito E, Tanaka H. Successful multidrug treatment of a pediatric patient with severe Churg-Strauss syndrome refractory to prednisolone. Tohoku J Exp Med. 2011; 225:117–121. PMID: 21914976.

17. Hirano F, Mizoguchi F, Harigai M, Miyasaka N, Kohsaka H. Tacrolimus successfully used to control refractory eosinophilic granulomatosis with polyangiitis complicated by invasive aspergillosis and chronic hepatitis B. Int J Rheum Dis. 2016; DOI: 10.1111/1756-185X.12869.

18. Ohe M, Kataoka H, Mukai M. A case of lupus nephritis treated with clarithromycin, tacrolimus, and glucocorticoids. Kaohsiung J Med Sci. 2016; 32:484–485. DOI: 10.1016/j.kjms.2016.04.007. PMID: 27638410.

19. Ohe M, Bohgaki T. A case of adult-onset Still's disease treated with monitoring of serum tacrolimus. Bull Hosp Jt Dis (2013). 2015; 73:213–216. PMID: 26535602.