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* From the Departments of Medicine, Brigham & Women’s Hospital and Harvard Medical School (Drs. Wechsler, Westlake, and Drazen), New England Medical Center (Drs. Finn and Gunawardena), Boston, MA; Oregon Health Sciences University (Dr. Barker), St. Francis Hospital and Medical Center (Dr. Haranath), Hartford, CT; and University Hospital (Drs. Pauwels and Kips), Ghent, Belgium.
Correspondence to: Jeffrey M. Drazen, MD, Pulmonary and Critical Care Division, Department of Medicine, Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115; e-mail: jdrazen{at}rics.bwh.harvard.edu
Study objectives: We previously reported eight patients who developed Churg-Strauss syndrome in association with zafirlukast treatment for asthma and postulated that the syndrome resulted from unmasking of a previously existing condition due to corticosteroid withdrawal and not from a direct drug effect. The availability of montelukast, a new leukotriene receptor antagonist with a different molecular structure, permitted us to test this hypothesis. Our goals were to ascertain whether the Churg-Strauss syndrome developed in patients taking montelukast and other novel asthma medications, and to describe potential mechanisms for the syndrome.
Design: Case series.
Setting: Outpatient and hospital practices of pulmonologists in the United States and Belgium.
Patients: Four adults (one man, three women) who received montelukast as treatment for asthma; two women who received salmeterol/fluticasone therapy, but not montelukast.
Results: Churg-Strauss syndrome developed in the four asthmatic patients who received montelukast. In each case, there was a long history of difficult-to-control asthma characterized by multiple exacerbations that had required frequent courses of oral systemic corticosteroids or high doses of inhaled corticosteroids for control. Two other asthmatics who received fluticasone and salmeterol but not montelukast therapy developed the same syndrome with tapering doses of oral or high doses of inhaled corticosteroids.
Conclusions: The occurrence of Churg-Strauss syndrome in asthmatic patients receiving leukotriene modifiers appears to be related to unmasking of an underlying vasculitic syndrome that is initially clinically recognized as moderate to severe asthma and treated with corticosteroids. Montelukast does not appear to directly cause the syndrome in these patients.
Key Words: asthma • Churg-Strauss syndrome • corticosteroid • leukotriene • montelukast • vasculitis
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