ASTHMA, TUBERCULOSIS OR EOSINOPHILIC PNEUMONIA?
Subhra Mitra1, Somenath Kundu2
A 45 year-old male presented with cough and expectoration for 8 months, short- lateral inﬁltrates on his chest radiographs. A mildly raised blood eosinophil count,
ness of breath and wheeze for 3 months, and fever for 1 month. He remained eosinophilia in broncho-alveolar lavage (BAL) ﬂuid and eosinophilic inﬁltration on
symptomatic despite repeated courses of antibiotics with partial relief on oral and CT guided FNAC from his lung lesion raised the suspicion and the dramatic clinico-
inhaled bronchodilators. Despite several sputum examinations being negative for radiological improvement with oral corticosteroids clinched the diagnosis of CEP.
acid fast bacilli (AFB), he was put on anti-tubercular drugs (ATD) because of bi-
Lung India 2007; 24 : 94-96
Key words : Chronic Eosinophilic Pneumonia, Blood Eosinophilia, Eosinophilic Lung Disease
Chronic eosinophilic pneumonia (CEP) is an
uncommon disorder that has a more protracted clinical
and radiological course than simple pulmonary eosinophilia
(Loefﬂer’s syndrome). Although etiology and pathogenesis
are unclear, a reagin (IgE) mediated hypersensitivity
pneumonitis has been strongly implicated.
We report here a case of CEP in a 45 year – old man
who presented with cough, shortness of breath, fever,
weight loss and an unexplained multifocal consolidation.
A 45-year-old male presenting with cough and
expectoration for 8 months, shortness of breath for 5 months
and fever for 1 month was admitted for evaluation. Fig.1 CXR 5 months prior to admission: Patchy inﬁltrates
He was apparently well till about 8 months back when
in the RUZ.
he started having cough with sputum production. Cough
was more common in the early morning and expectoration,
mucoid and sometimes mucopurulent, varied from ½ to 1
cup per day. There was no foul odour or blood streaking
of the sputum. The symptoms persisted despite cough-
medicines and repeated courses of antibiotics.
After three months of his illness he started having
episodes of shortness of breath with wheeze that showed
only partial relief on oral and inhaled bronchodilators and
oral steroids for 10 days. There was no history of orthopnoea
or paroxysmal nocturnal dyspnoea. One month prior to his
admission he developed a low grade, intermittent fever with
temperature ranging between 990 and 1010 F, night sweats
but no chills or rigors.
He was prescribed anti-tubercular drugs elsewhere, Fig. 2 CXR 1 month prior to admission: Patchy shadows
based on his chest radiographs (Fig. 1 & 2). The patient – both mid zones.
Associate Professor, Department of Respiratory Medicine
Institute of Postgraduate Medical Education & Research and S.S.K.M. Hospital, Kolkata-700020
Correspodence : Dr. Subhra Mitra, 701 Auroville Apartments, 10, Mandeville Gardens, Kolkata 700019, E-mail : firstname.lastname@example.org
Received : November 2006
Accepted : January 2007
Asthma, Tuberculosis or Eosinophilic Pneumonia?
complained of weakness and anorexia during the last three
months of his illness and had lost weight more than 10
The patient gave no history of diabetes, hypertension,
asthma, skin rash, arthritis, sinusitis, dysuria, haematuria, or
contact with tuberculosis and pet birds or any risk factor for
HIV infection. He was a smoker for 15 years before quitting
about 14 years ago. He is an accountant in a packaging ﬁrm
with history of exposure to water-based varnish coating.
On physical examination the patient looked ill
and toxic. There was no clubbing, edema cyanosis,
lymphadenopathy or skin lesion. His temperature was 990
F, pulse 108/min., respiration 24/min, BP 130/80 and JVP
was not raised. There were bilateral scattered rhonchi and Fig. 4 Bilateral confluent alveolar opacities with air
a few inspiratory crackles. Other ﬁndings were within bronchograms.
normal limits. On admission he was put on IV antibiotics,
inhaled bronchodilators and ATDs were discontinued.
His chest radiographs (cxr) showed
Haemoglobin 13.2 gm/dl, Platelet count 290,000/mm3,
WBC: 12,900/mm3, Neutrophil: 77% Capymphocyte: 15%
Monocyte: 1% Eosinophils: 7% (abs count 903/mm3),
absolute Basophil: 0%, ESR: 101mm. A peripheral blood
smear done 4 months prior to admission showed WBC
11,200 with eosinophils 14% and another done 1 month
prior to admission showed WBC 8,600 with eosinophils 5%
and ESR 105mm.
Fig. 5 CXR 2 weeks after starting oral steroids showed near-
complete radiological resolution.
Spirometry showed mixed obstructive and restrictive
ventilatory defect. C-ANCA & p-ANCA: Negative
IgE: 241.09 kIU/L (<120 kIU/L) C.T. scan of thorax
(Fig. 4): bilateral conﬂuent alveolar opacities with air
BAL ﬂuid: 960 cells/mm3 with eosinophil 20%. Stains
for AFB and fungus were negative. Malignant cells were
CT-guided FNAC from Rt Lung showed many
scattered eosinophils, polymorphs along with degenerated
cells. Charcot-Leyden crystals were noticed. Stain for AFB
Fig. 3 CXR on admission: Dense inﬁltration, more in the was negative. Findings were consistent with eosinophilic
L mid zone. pneumonia.
The patient was put on oral prednisolone 40mg/day
Blood sugar, urea, serum creatinine, and liver function and IV antibiotics were discontinued.
tests, urine microscopy were normal. Sputum for AFB was
He was afebrile on the 2nd day. Cough and
negative on smear and culture. HIV serology was negative,
expectoration diminished (sputum 10-15 ml/day). His
USG abdomen was normal.
appetite improved and he gained 3 kg. His CXR (Fig. 5) 2
weeks after starting oral steroids showed near-complete co-relates with presence of tissue eosinophilia on lung
radiological resolution. biopsy. BAL ﬂuid often contains > 20% eosinophils in acute
phase of CEP5. Open lung biopsy may be required if there
Oral prednisolone 40 mg/day was continued for 2
is diagnostic doubt2 but because of associated perioperative
weeks; then gradually tapered off over a period of 9 months.
morbidity we opted for CT-guided FNAC6 of the lung
He is now asymptomatic, off oral steroids but on inhaled
consolidation which showed eosinophilic inﬁltrates and
corticosteroids and is attending for follow-up for more than
Swift clinico-radiological improvement with
corticosteroids is a characteristic feature of CEP rarely
The term chronic eosinophilic pneumonia was observed with other inﬂammatory lung disorders, and may
coined by Carrington and colleagues1 in 1968 to describe a help to conﬁrm a suspected case.2,4,5 Our patient showed
condition characterized by presence of blood eosinophilia considerable symptomatic improvement by the second day
and pulmonary eosinophilic inﬁltration for which no cause of oral steroids with radiologic clearance in two weeks. The
is found. CEP usually occurs in middle aged women but corticosteroid dosage is tapered off over 12-18 months2,5 as
can occur at any age in either sex2. Cough with mucoid or recurrence is common with rapid weaning off steroids. Our
no sputum, dyspnoea, weight loss, malaise, wheezing and patient is on follow-up for more than a year and is off oral
night sweats are the main symptoms2. Asthma is present steroids for 3 months.
in half of the cases and tends to be of recent onset3.
A diagnosis of CEP requires a high index of suspicion.
Our patient had asthma-like symptoms of recent CEP may mimic common lung disorders like tuberculosis.
onset for which he was managed elsewhere before a more Migrating inﬁltrates on serial radiographs are a clue to
deﬁnite diagnosis of CEP was made in this department. immunologic disorders. Dramatic response to corticosteroid
Blood eosinophilia though typical may be absent1. Only therapy is an important aid to the diagnosis often helping
mild peripheral eosinophilia was documented on two to conﬁrm suspected case.
occasions in our patient. ESR and serum IgE are raised in
most patients but may be normal2.
1. Carrington CB, Addington WW, Goff AM, et al: Chronic
The classical radiologic features of peripheral eosinophilic pneumonia. N Engl J Med 1969; 280: 787-798.
pulmonary infiltrates – “reverse pulmonary oedema 2. Goetzl EJ, Luce JM. Eosinophilic Lung Diseases. In Murray JF,
pattern” – was not present in our case but the serial Nadel JA (ed): Textbook of Respiratory Medicine, 3rd Ed, WB
radiographs suggested that the inﬁltrates were changing. Saunders 2000: 1757-1773.
So with the more common conditions like tuberculosis
3. Fox B, Seed W: Chronic eosinophilic pneumonia. Thorax 1980;
and necrotizing pneumonia, we considered some largely 35: 570-580.
immunologic conditions like allergic bronchonulmonary
4. Fraser RS, Muller NL, Colman N, Pare PD. Eosinophilic Lung
aspergillosis (ABPA), Wegeners’ granulomatosis, BOOP
Disease. In Diagnosis of Diseases of the Chest, 4th Ed, WB Saunders
and CEP. However, compared to the ﬂeeting nature of 1999; 1743-1756.
consolidations in simple pulmonary eosinophilia, the lesions
5. Kroegel C, Reissig A, Mock B. Eosinophilic pneumonia. In Gibson
in CEP tend to persist unchanged over days4 or be partially
GJ, Geddes DM, Strek PJ, Costable U, Corrin B (ed): Respiratory
ﬁxed and partially evanescent. CT conﬁrms the peripheral Medicine, 3rd Ed, Saunders 2003: 1643-1659.
distribution of the consolidation4 as in our patient.
6. Ramzy I, Geraghty R, Lefcoe MS, et al: Chronic eosinophilic
BAL eosinophilia is a reliable clue to presence pneumonia. Diagnosis by ﬁne needle aspiration. Acta Cytol 1978;
of eosinophil-related disorders of the lung and closely 22: 366.