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Idiopathic eosinophilic pneumonia

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					Idiopathic Eosinophilic Pneumonia

Dr. Hadil Alotair KKUH

History
A 18 Y/O saudi lady living in Riyadh. she is a student – C/O •Fever •productive cough •Chest pain •Dizziness+syncope

8 days 8 days 2 days 2 days

– She was seen in a private hospital and was given Augmentin and azithromycin for five days without any improvement.
Past H/O
– BA – Eczema – Allergic rhinitis – WPW

Drug Hx
•Budesonide •Flexinase •Ventolin •Singulare

Examination
• looked sick. • Pulse 125/minute, BP 108/67 mm Hg. • Temperature 37. 8c. • Respiratory rate 22/minute. • No lymphadenopathy. • 02 saturation was 88% on room air.

• Chest

– Decreased chest expansion on the right side – Dull ness – Bronchial breathing Rt. Infrascapular – Coarse crepitations – Pleural rub • Other systemic examination- NAD

Investigations
• CBC:
– – – – – WBC 29,000 RBC 4.5 Hb 137 Plt 327 ESR 14.

• Differential: neut 51, lymph 14,mono 5, eos 30% • Urea and electrolytes: Normal • LFT – Normal.

• ABG: – pH – PC02 – Po2 – HC03 – 02 saturation

7.43 36 51.9 23.2 87.9 on RA

Hospital course
• The patient was admitted initially with the impression of - CAP • on the following day
– increasing SOB , cough -- Desaturated.

• she was transferred to the MICU

MICU
• In MICU -- Ceftriaxone increased (2 g iv BD)
– CIarithromycin – along with 02 10 lt – active nebulization with Ventolin, Atrovent and Pulmicort,

• ABG on 10 l o2 via NRBM
– PH 7.39 Pco2 41 Po2 88 HCo3 24

• She was put on non invasive ventilation BIPAP 60% O2
IPAP-10 EPAP-4

• Her blood culture - Streptococcus pneumoniae
• Meropenem and levoftoxacin • she was not responding to BiPAP

• hemodynamically unstable – inotropes
• She was Intubated

• Her ventilator mode was
– ACMV ,PEEP 10, FIO2 60%, Vt 350, RR 22

pH – 7.49 PCO2- 42 PO2- 85 HCO3 – 31 %O2Sat-97
– CT scan showed
•Large pneumonic consolidation of the right lung with para pneumonic effusion •Dense opacification in the apical segment of left lower lobe •Early ARDS.

• At this stage the DDx was: – CAP – ABPA – Churg Strauss Syndrome – Pulmonary eosinophilic syndrome such as •Loffler’s syndrome •Acute eosinophillic pneumonia •Hyper eosinophilic syndrome – Drug induced

Investigation results
• PLF – Negative for malignant cells
•

– Inflammatory infiltrate consists mainly of neutrophil mixed with moderate no. of eosinophil & few plasma cells & lymphocytes

Bronchial lavage : Eosinophils – 35% Negative for malignant cells. Negative for fungal element and gram staining and AFB

• Endobronchial biopsy:
Marked eosinophilic infiltration in bronchial mucosa.

•Skin biopsy:
Drug related dermatitis.

Methylprednisolone 40 mg iv q8h
• Improved

• Extubated - 5 days

Results of pending investigations
• Serum Aspergillus antibodies: Negative for all variants. • Serum anti-mycoplasma IgM: Negative • ANA, Anti DNA – Negative • ANCA – Negative

Etiology
• Acute hypersensitivity reaction to inhaled antigen in a previously healthy Individual • Enviromental factors • Cigarette smoking • World trade centre • Military personnel in Iraq • HIV

Clinical presentation
• • • • • Cough Dyspnea Pleuritic chest pain Myalgia Night sweats

Physical exam
• • • • • Fever Tachypnea Tachycardia Bibasilar crackers rhonchi

Complication
• Hypoxemic respiratory failure • 14 of 22 patients(63%) required MV • Hyper dynamic Shock

Lab
• • • • Neutrophilia Eosinophilia IgE ESR

CXR
• • • • • Reticular infiltrate Kerly B line Bil.diffuse alveolar &reticular opacities Isolated reticular or alveolar Small bil effusion)Eosinophilic)

HRCT
• Bil.patchy ground glass or reticular opacities • Effusion

BAL
• • • • • Eosinophilia >25%(mean 37%) IL-5 GM-CSF IL-1ra VEGF

Pathology
• Acute &organising diffuse alveolar damage • Interstitial&alveolar &bronchiolar infiltration of eosinophil • Hyaline membranes and interstitial widening • Organising intra alveolar fibrinous exudate

Treatment
• • • • • Spontaneous improvement rare Resp. failure (50-60%) Steroids Clinical response 12-48 hrs Continue steroids for 2-4 wks after plain Xray normalises (2-6wks)

ACR – Classification Critera:


Asthma



Eosinophilia of > 10%
Mono or poly-neuropathy





Migratory or transient pulmonary opacities
Para-nasal sinus abnormalities Biopsy containing blood vessel –extra vascular eosinophils






				
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