Eosinophilic PneumoniaAbdalmohsen AbabtainSenior ResidentSaudi Board for Emergency MedicineMarch 31st 2013Supervised by :Dr Ghassan Alghamdi
Case 19 Years old Presented to ER with SOB and Sore throat and fever for 2 Days after coming Back from Makkah Has a Hx of atopy (SOB from Dust) with positive Family history too He Started to smoke cigarettes a week ago (a cigarette/day)
Exam T 36.8 P:122 BP 120/65 RR 30 SpO2 79% RA Patient looks in Respiratory Distress In Tripod Position Equal Bilatral Airentry No Wheeze, No Stridor nor drooling
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Eosinophilic Lung Diseases Group of Disorders with high eosinophils in Lung Parenchyma The Defining Characteristics include either:1. Peripheral Blood Eosinophilia with Radiological Pulmonary Abnormality2. Lung tissue eosinophilia in Biopsy3. High eosinophils in BAL
Toxins Scorpion stings Inhalation of heroin or crack cocaine Inhalation of organic chemicals during rubber manufacture Inhalation of dust or smoke Abuse of 1,1,1-trichloroethane (Scotchguard)
Acute eosinophilic pneumonia Acute febrile illness with Severe hypoxaemia, Diffuse pulmonary infiltrates Increase in bronchoalveolar lavage (BAL) eosinophils No evidence of infection or Drug ingesion
Less than 100 cases of AEP have been reported to date The largest series including only 33 patients An epidemiologic study of this disease identified 18 patients with AEP among183,000 US military personnel deployed in Iraq, all of them were smokers, with 78% of them recently beginning to smoke Chest 2008; 133: 1174–1180 JAMA 2004; 292:2997–3005
Inhalational exposuresassociated with AEP Smoke (Most common specially first time) Passive smoking* !! World Trade Center demolition dust Firework Tear gas bomb explosion Gasoline tank cleaning Cave exploration Woodpile moving Chest 2000;117:277–279 *Allergology International. 2010;59:421-423
Physical Exam Fever Tachypnea Bibasilar inspiratory crackles or could be clear in 20% of Patients Hypoxemic respiratory insufficiency is frequently identified at presentation and often requires mechanical ventilation Semin Respir Crit Care Med. 2006 Apr;27(2):142-7.
Labs Patients generally present with an initial neutrophilic leukocytosis Blood eosinophilia, However, the absence of it does not exclude these conditions. Any concomitant glucocorticoid therapy will suppress blood eosinophilia The magnitude of blood eosinophilia is not a reliable means to distinguish the possible etiologies of pulmonary eosinophilia. High ESR !
Imaging At the Start, Subtle reticular or ground glass opacities, often with Kerley B lines Small pleural effusions are common
Imaging High resolution CT ground-glass attenuation, airspace consolidation, poorly defined nodules. The triad of • Interlobular septal thickening, • Bronchovascular bundle thickening, and • Pleural effusionsare most suggestive AEP
Biopsy If BAL is not Revealing Biopsy, via a transbronchial or open lung biopsy or VATS approach depending upon the clinical and radiographic findings
Cultures If there have been appropriate geographic exposures for coccidioidomycosis or clinical and radiographic findings suggestive of ABPA, fungal cultures should be obtained
AEP is a diagnosis of exclusionand Requires : An acute febrile illness of short duration (usually less than one week) Hypoxemic respiratory failure Diffuse pulmonary opacities on chest radiograph BAL eosinophilia >25 percent Lung biopsy evidence of eosinophilic infiltrates (acute and/or organizing diffuse alveolar damage with prominent eosinophilia is the most characteristic finding) Absence of known causes of eosinophilic pneumonia, including drugs, infections.
Treatment1. Glucocorticoid administration (preferably after blood extraction) is medically indicated if: Hypoxemia and in respiratory distress If the etiology is either AEP or a medication or toxin-elicited AEPRegimens : In the absence of respiratory failure, initial treatment is with oral prednisone (40 to 60 mg daily). In the presence of respiratory failure, methylprednisolone (60 to 125 mg every 6 hours) Optimal Duration is not yet clear (2-4 wks no diff)* *Eur Respir J 2013; 41: 402–409
After ImprovmentContinue oral prednisone in a dose of 40-60 mg per day for 2-4 weeks2. Supportive Therapy3. Smoking Cessation
Recurrence Relapse is uncommon and is usually associated with resumption of cigarette smoking after initial cessation
Refrences Up to date Eur Respir J 2013; 41: 402–409 Chest 2008; 133: 1174–1180 JAMA 2004; 292:2997–3005 Chest 2000;117:277–279 Semin Respir Crit Care Med. 2006 Apr;27(2):142-7.