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EGPA Flare — SCE Rheumatology MCQ

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HardVasculitisEGPA FlareSCE Rheumatology

A 60-year-old man with EGPA in remission on Mepolizumab develops persistent eosinophilia (2.8 x10^9/L) with new asthma exacerbation and sinusitis but no evidence of vasculitis. What is the most likely explanation?

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Correct answer: B — Eosinophilic flare of EGPA without vasculitis requiring optimisation of Mepolizumab and glucocorticoid adjustment

EGPA has distinct phases: eosinophilic (asthma and eosinophilia without vasculitis) and vasculitic (organ-threatening vasculitis). Mepolizumab (anti-IL-5) primarily targets the eosinophilic component. A rise in eosinophils with asthma and sinusitis exacerbation but without vasculitic features suggests eosinophilic flare rather than vasculitic relapse. Management involves optimising Mepolizumab dosing and adjusting glucocorticoid dose. Vasculitic flare would require escalation to Cyclophosphamide or Rituximab. Infection (particularly parasitic) should be excluded.

Reference: ACR/VF 2021 AAV guideline; Wechsler ME et al 2017 MIRRA trial