Dupilumab-Induced Systemic Hypoperfusion in an Elderly Patient: A Case Report

Dupilumab is generally considered safe and effective for treating bullous pemphigoid (BP). We report the first case of recurrent hypoperfusion-induced cerebral infarction temporally associated with dupilumab administration in an elderly patient.

A 96-year-old male with BP, type 2 diabetes, and a history of stroke developed acute hypotension, depressed consciousness, and reduced oral intake within 24-72 hours after three separate dupilumab injections. Initial neuroimaging revealed watershed infarcts. Proactive volume expansion during one administration successfully averted new infarction, whereas lack of prophylactic hydration on another occasion precipitated a transient ischemic attack (TIA).

A significant temporal association was documented. The Naranjo Adverse Drug Reaction Probability Scale score was 8, indicating a probable association. The patient's advanced age, compromised cerebrovascular reserve, and mandatory discontinuation of antithrombotics created a hypervulnerable substrate. The hypotensive mechanism is hypothesized to involve IL-4/IL-13 pathway blockade, potentially disrupting endothelial function and vascular tone regulation.

This case report describes a potential, albeit rare, serious adverse effect associated with dupilumab in an elderly individual at high risk. Based on this single experience, we suggest at least 72 hours of post-injection blood pressure monitoring for high-risk patients. Management could include administering prophylactic fluid replacement based on the patient's actual condition and critically reassessing concomitant antihypertensive regimens. This finding highlights the need for heightened clinical vigilance and suggests that the drug's safety profile in advanced-age patients may warrant further investigation.