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ASTHMA TUBERCULOSIS OR EOSINOPHILIC PNEUMONIA

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					     Case Report

                        ASTHMA, TUBERCULOSIS OR EOSINOPHILIC PNEUMONIA?
                                                                 Subhra Mitra1, Somenath Kundu2

ABSTRACT
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

INTRODUCTION
     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.
CASE REPORT
     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.

1,2
   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 : susa@vsnl.net
Received : November 2006
Accepted : January 2007

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                                                                                             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
kgs.
     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
Laboratory investigations
      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
                                                                        bronchograms.
                                                                              BAL fluid: 960 cells/mm3 with eosinophil 20%. Stains
                                                                        for AFB and fungus were negative. Malignant cells were
                                                                        not found.
                                                                               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
                                                                   95
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
                                                                    Charcot-Leyden crystals.
a year.
                                                                          Swift clinico-radiological improvement with
DISCUSSION
                                                                    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.
                                                                    REFERENCES
                                                                    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.




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