Benralizumab for eosinophilic granulomatosis with polyangiitis and subclinical cardiac involvement: A fertility-preserving case report.

Cardiac involvement, which may remain clinically silent, is a major determinant of prognosis in eosinophilic granulomatosis with polyangiitis, and remission induction generally requires glucocorticoids (GCs) combined with cyclophosphamide or rituximab. In contrast, treatment selection may be challenging in women wishing to preserve fertility because cyclophosphamide carries a risk of gonadal toxicity. We report the case of a 40-year-old woman with a history of asthma, eosinophilic chronic rhinosinusitis, and eosinophilic otitis media who developed postpartum-onset eosinophilic granulomatosis with polyangiitis and presented with neurological and cutaneous manifestations. Elevated cardiac troponin I levels and newly developed electrocardiographic abnormalities suggested subclinical myocardial injury despite the absence of cardiac symptoms. Intravenous methylprednisolone pulse therapy was initiated immediately. Because cardiac troponin I levels showed no early decline after GC initiation, and GC monotherapy was considered potentially insufficient to control eosinophil-mediated myocardial injury, additional eosinophil-targeted therapy was selected after shared decision-making that balanced fertility preservation with the need for prompt disease control. Benralizumab was chosen because of its potent eosinophil-depleting effect. Peripheral eosinophils rapidly decreased to zero, troponin I normalised by Day 26, and GCs were successfully discontinued within 5 months. To our knowledge, this is the first report of benralizumab used as part of a fertility-preserving remission-induction strategy to avoid cyclophosphamide in a woman with eosinophilic granulomatosis with polyangiitis and cardiac involvement. This approach may represent an individualised therapeutic option for carefully selected patients in whom fertility preservation is an important treatment consideration.