This document summarizes a case of acute eosinophilic pneumonia. A 19-year-old male presented with shortness of breath, sore throat, and fever after returning from Mecca. Exams found respiratory distress and hypoxemia. Tests showed elevated white blood cells and eosinophils in the lungs. Acute eosinophilic pneumonia was diagnosed based on lung biopsy findings and exclusion of other causes. The patient was treated with corticosteroids and supportive care and had an improvement in symptoms. Acute eosinophilic pneumonia is a rare lung disease characterized by lung tissue eosinophilia and often associated with smoking or other inhalational exposures.

1. Eosinophilic Pneumonia
Abdalmohsen Ababtain
Senior Resident
Saudi Board for Emergency Medicine
March 31st 2013
Supervised by :
Dr Ghassan Alghamdi

2. 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)

3. 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

5. Labs
 WBC 25.6 (mostly Nuetrophilic)
 Lactate 12.3
 Urine Tox Negative
 BG :
 PH 7.27 Co2 30 Po2 85 Hco3
14

6. In ER
 Asthma Management Started In ER
 Patient continue to Deteriorate
 Tubed !
 HIGH Peak and Airway Pressure !

7. In ICU
 H1N1 & Influenza & Parainfluenza and
AFB Negative
 Lactate started to Normalized
 BAL Done and ShowedEos 14%
Acute Eosinophilic Pneumonia
!!!

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12. Eosinophilic Lung Diseases
 Group of Disorders with high
eosinophils in Lung Parenchyma
 The Defining Characteristics include
either:
1. Peripheral Blood Eosinophilia with
Radiological Pulmonary Abnormality
2. Lung tissue eosinophilia in Biopsy
3. High eosinophils in BAL

13. Eosinophilic Lung Diseases
 Acute Eosinophilic Pneumonia (AEP)
 Chronic Eosinophilic Pneumonia (CEP)
 Helminthic Infections (Löffler's syndrome)
 Non-Helminthic Infection (Coccidioidal
infection)
 Medications (NSAID)
 Toxins
 Churg-Strauss Syndrome
 Allergic Bronchopulmonary Aspergellousis
(ABPA)

14. 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)

15. 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

16.  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

18. Inhalational exposures
associated 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

19. Approach
History :
 Chief complain and Associated symptoms
 Medication
 Chemical and occupational Exposure
(NSAID, Dust, Smoke)
 Travel Hx (Fungal inf.)
 Respiratory Hx (Asthma)
 Extrapulmonary Involvment

20. 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.

21. 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 !

22. Imaging
 At the Start, Subtle reticular or ground
glass opacities, often with Kerley B
lines
 Small pleural effusions are common

23. Imaging
 High resolution CT ground-glass
attenuation, airspace consolidation,
poorly defined nodules.
 The triad of
• Interlobular septal thickening,
• Bronchovascular bundle thickening,
and
• Pleural effusions
are most suggestive AEP

24. Eur Respir J 2013; 41: 402–409

25. BAL

26. Biopsy
 If BAL is not Revealing
 Biopsy, via a transbronchial or open
lung biopsy or VATS approach
depending upon the clinical and
radiographic findings

27. Cultures
 If there have been appropriate
geographic exposures for
coccidioidomycosis or clinical and
radiographic findings suggestive of
ABPA, fungal cultures should be
obtained

28. AEP is a diagnosis of exclusion
and 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.

29. Treatment
1. 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 AEP
Regimens :
 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

30. After Improvment
Continue oral prednisone in a dose of
40-60 mg per day for 2-4 weeks
2. Supportive Therapy
3. Smoking Cessation

31. Recurrence
 Relapse is uncommon and is usually
associated with resumption of
cigarette smoking after initial
cessation

32. 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.

33. Thank You