A 57-year-old woman was admitted to our hospital for an asthma attack. She was a heavy smoker with a history of asthma, insulin-dependent diabetes mellitus, and pulmonary tuberculosis. Chest auscultation revealed wheezing and rhonchi. Laboratory findings revealed peripheral blood eosinophilia (655/muL) and a total IgE value of 163 IU/mL. Chest radiography revealed scar lesion. High-dose ICS, LABA, and systemic corticosteroid (prednisolone 40mg/day) therapy induced symptom improvement. Six months later, she required Symbicort 8 puffs/day, QVAR100  (beclometasone) 4 puffs/day, theophylline 400 mg/day, and montelukast 10 mg/day. The wheezing and asthma attacks continued. Omalizumab (300 mg every 4 weeks) was started; her symptoms improved after 24 weeks, but then worsened. After 15 months, the FVC and FEV1 were 0.86 L (%FVC 32.2%) and 0.42 L (%FEV1 19.4%), respectively. Mepolizumab treatment (100 mg every 4 weeks) was started.
Ten months later, the peripheral eosinophil count decreased from 1350/mul to 60/muL. Spirometry revealed improved lung function (%FVC 86.7%; FVC 2.29 L; %FEV1 44.6%; FEV1: 0.95 L). The FeNO increased from 41 ppb to 75 ppb. The ACT was 24. However, the asthma attaks continued. Benralizumab was started (30 mg subcutaneously every 4 weeks for the initial three doses and then every 8 weeks). The eosinophil count decreased from 60 to 0/muL after 1 month. Asthma flares were markedly decreased after 6 months. The ACT was 23. The FVC and FEV1 were further improved (Table 1).