DUPILUMAB INDUCED EOSIPHILIC CELLULITIS (WELLS SYNDROME) AND SUCCESSFUL TREATMENT WITH BINRALIZUMAB

Wells Syndrome was described first on 1971(1), It's a rare condition with only 200 documented cases in the literature. The first case of wells syndrome treated by Dupilumab was reported on 2019(2). This is a case of a 24-year-old female presented to Allergy and Immunology clinic for treatment of refractory AERD with AFRS. She was started on Dupilumab loading dose of 600mg then 300mg SC Q2weeks, However, after the4 th dose she developed afew deep vesicles over the soles and palms with multiple post inflammatory hyperpigmented lesions over feet and hands. Dupilumab was held. She improved partially at the time and resumed Dupilumab after 2 months but started to have recurrence of cutaneous symptoms after the3 rd dose with increasing severity which continued to worsen even after starting steroids and holding Dupilumab, in concordance with gradual increase of peripheral Eosinophilia and steep uprising after 3rd dose reaching up to (18.83x10^9/L). Skin biopsy showed the characteristic granulomatous reaction with flame figure and a superficial and deep perivascular and interstitial eosinophilic infiltrate indicating Wells syndrome. Steroids had a modest effect so eventually shifted to Binralizumab 30mg/ml Q4weeks for the first 3Months then 30mg/ml Q8weeks, which led to remarkable improvement of her condition. Dupilumab is favored in refractory Wells syndrome for its effect of blocking Th-2 pathway by blocking IL-13,IL-4, and decreasing tissue Eosinophilia. Flare of symptoms observed after restarting Dupilumab, this can be to initial transient Eosinophilia that can persist for approximately 16-20 weeks after initial dose(8).