Acute eosinophilic pneumonia: a hypersensitivity phenomenon?

A previously healthy young man presented with acute respiratory distress and diffuse bilateral infiltrates on chest radiograph. Eosinophilic pneumonia was diagnosed by bronchoalveolar lavage and confirmed by transbronchial lung biopsy. There was no evidence of an infectious etiology, and the patient rapidly improved with corticosteroid therapy. Most cases of eosinophilic pneumonia reported previously have followed a chronic course. The case presented here was acute in onset, suggesting a hypersensitivity reaction. High levels of bronchoalveolar lavage eosinophils indicate the diagnosis but not the etiology of eosinophilic pneumonia.     

The eosinophilic pneumonias

Acute and chronic eosinophilic pneumonia can be distinguished by their clinical, laboratory, and radiographic features. Patients with both acute and chronic eosinophilic pneumonia present with cough, dyspnea, and fever. Patients with chronic eosinophilic pneumonia present subacutely over weeks to months but patients with acute eosinophilic pneumonia present within 5 days of symptom onset. Chest radiographs in chronic eosinophilic pneumonia show peripheral alveolar infiltrates. In contrast, radiographs in acute eosinophilic pneumonia show mixed interstitial and alveolar infiltrates, Kerley B lines, and pleural effusions. Both disorders are characterized by high percentages of bronchoalveolar lavage eosinophils, but high numbers of blood eosinophils accompanies only chronic eosinophilic pneumonia. The diagnosis of both disorders can usually be made based on clinical and radiographic findings; however, lung biopsy is occasionally necessary to distinguish the eosinophilic pneumonias from other eosinophilic lung diseases. In both conditions, patients will respond rapidly and completely to corticosteroids but patients with chronic eosinophilic pneumonia usually relapse if less than 6 months of treatment is given, whereas patients with acute eosinophilic pneumonia do not relapse after a brief course of treatment.     

Chronic eosinophilic pneumonia due to visceral larva migrans

A 38-year-old woman presented with worsening cough, blood eosinophilia, and pulmonary infiltrates. Bronchoalveolar lavage showed 96.4% eosinophils. The diagnosis of visceral larva migrans (VLM) was made based on the positive results in enzyme-linked immunosorbent assay for Toxocara canis together with clinical symptoms and laboratory data. Pulmonary infiltrates due to VLM generally manifest as a transient form of L?ffler's syndrome or simple eosinophilic pneumonia mainly in children. Here we report an adult case of VLM, with pulmonary infiltrates pathologically proven to be eosinophilic pneumonia, which persisted for 7 weeks before anthelmintic treatment with albendazole and manifested as chronic eosinophilic pneumonia.     

Positive response to smoking challenge test in a case of acute eosinophilic pneumonia]

A 19-year-old man presented with an acute febrile illness and progressive dyspnea. He had begun smoking two weeks before admission. A chest X-ray film revealed Kerley B lines and diffuse infiltration in both lungs. Analysis of bronchoalveolar lavage fluid showed 21% eosinophils. The patient had no history of hypersensitivity to drugs, nor was there any evidence of infectious disease. Acute eosinophilic pneumonia was diagnosed, and his condition improved without steroid treatment. A smoking challenge test was performed. After the test, the patient's body temperature rose to 38.0 degrees C, computed tomograms of the chest showed increased density, and elevated eosinophil levels were again detected in bronchoalveolar lavage fluid. These findings supported the view that beginning to smoke can be a cause of acute eosinophilic pneumonia.     

Favorable response to asthma-dosed subcutaneous mepolizumab in eosinophilic pneumonia

Introduction: Mepolizumab targets eosinophils in the treatment of asthma. The dose used for asthma is considerably lower than that used for treating eosinophilic granulomatosis with polyangiitis, a recently approved indication. While intravenous mepolizumab use has reported utility in non-asthma eosinophilic disorders, the efficacy of the subcutaneous asthma dosing of the drug for eosinophilic pneumonia is not known. Case study: A middle-aged female was diagnosed with eosinophilic pneumonia. The patient’s clinical/radiologic/laboratory findings, response to treatment, and respiratory function studies are described. Results: A woman, born in 1962, had repeated pneumonia hospitalizations from 2007 through 2010. In October 2010, a lung biopsy showed findings consistent with chronic eosinophilic pneumonia and chronic asthma. The patient also had chronic sinusitis. Long term systemic corticosteroids were prescribed but the patient became oxygen dependent by 2014. Omalizumab was administered for 1 year starting in 2015 without improvement in symptoms. In 2016, mepolizumab 100?mg subcutaneously every 4?weeks was initiated. Symptomatic improvement with decreased oxygen and systemic corticosteroid requirements were noted. A chest CT performed in February 2018 showed marked improvement compared to a study in 2016. Interval spirometric improvements were noted. Peripheral blood eosinophils/mm³ prior to mepolizumab were 237, and while on mepolizumab were 10. Conclusion: Parenchymal eosinophilic lung disease may respond to asthma-dosed mepolizumab. Mepolizumab treatment in asthma where concomitant interstitial disease is suspected, may offer an advantage over omalizumab in the ability to reduce eosinophils not only in airways, but also in lung parenchyma.     

Neumonía eosinofílica crónica: ¿fenómeno autoinmune o enfermedad inmunoalérgica? Reporte de un caso y revisión de literatura

Eosinophilic pneumonia is classified by its acute or chronic presentation, the distinguishing characteristics of which are based on the presence of cough, dyspnea, fever and pulmonary infiltrates with accumulation of inflammatory cells, predominantly eosinophils. The association of eosinophilia and rheumatologic disorders is well known, as in the case of eosinophilic fasciitis and the Churg-Strauss syndrome. The coexistence of chronic eosinophilic pneumonia and rheumatoid arthritis has been reported, either early rheumatoid arthritis of definitive disease. The pathophysiological role of eosinophils in autoimmune diseases is not well defined, however it has been shown that the production of pro-inflammatory cytokines stimulate and activates different cell groups, and can simultaneously induce autoantibodies and/or increased infiltration of eosinophils in various tissues, without an underlying autoimmune disease. The case of a young woman with rheumatic chronic eosinophilic pneumonia manifestations and the presence of autoantibodies, which resolved spontaneously, is presented here.     

Acute eosinophilic pneumonia induced by cigarette smoking]

The subject was a 24-year-old man who presented with acute fever, dry cough, and dyspnea. Chest X-ray films revealed diffuse infiltrates in both lungs. Bronchoalveolar lavage fluid specimens contained an increased number of eosinophils. Transbronchial lung biopsy specimens demonstrated the infiltration of eosinophils into alveolar walls and air spaces. These findings were consistent with acute eosinophilic pneumonia. The patient recovered without medical treatment. Eight days prior to admission, he had resumed smoking after 3 years of abstention. It was suggested that the cause of acute eosinophilic pneumonia in this case was associated with the resumption of smoking. To confirm that association, a smoking challenge test is usually necessary. However, similar symptoms also developed later, after the patient was passively exposed to cigarette smoke. Therefore, we concluded that smoking was probably the etiologic agent of his illness.     

Chronic eosinophilic pneumonia associated with rheumatoid arthritis]

We encountered a 45-year-old woman with chronic eosinophilic pneumonia associated with rheumatoid arthritis. In May 1997, she was given a diagnosis of rheumatoid arthritis and prescribed non-steroidal anti-inflammatory drugs. After a month, she visited our hospital because of fever and cough. A chest roentgenogram and computed tomographic scan on first admission revealed peripheral infiltrative shadows in the upper fields of both lungs. Approximately 30% of peripheral blood cells were eosinophils. Furthermore eosinophils were elevated in bronchoalveolar lavage fluid and transbronchial lung biopsy specimens. A conclusive diagnosis of chronic eosinophilic pneumonia was made on these grounds. The patient responded well to steroid treatment, but was readmitted a week later because of worsening joint pain and skin eruptions in the lower extremities of both legs. A skin biopsy showed perivascular and interstitial eosinophil infiltration. The combination of steroids, a disease modifying anti-rheumatic drug, and a non-steroidal anti-inflammatory drug proved to be effective.     

慢性嗜酸粒细胞肺炎的研究进展

慢性嗜酸粒细胞肺炎是一种病因不明的慢性肺嗜酸粒细胞性炎症,临床表现无特异性,其特点为周围性肺浸润影;外周血和(或)支气管肺泡灌洗液中嗜酸粒细胞数显著增高;抗感染治疗无效而对糖皮质激素的反应良好,但在减量或停用糖皮质激素时容易复发.     

Acute eosinophilic pneumonia associated with smoke from fireworks

We report a case of acute eosinophilic pneumonia (AEP). Although the patient had been a habitual cigarette smoker for over 4 months, he had had not any respiratory distress. After he inhaled smoke from fireworks for 3 consecutive nights, the patient began to complain of cough, fever and dyspnea. He showed leukocytosis of 16,200/microl and hypoxemia of 58.1 torr. Chest radiograph showed bilateral infiltrates with Kerley A and B lines. The bronchoalveolar lavage fluid revealed 38.5% eosinophils. He was diagnosed as AEP. In this patient, inhaling of smoke from fireworks was clinically suspected to be associated with the induction of AEP.     

Eosinophilic pneumonia due to duloxetine

A 32-year-old man presented with a 2-month history of worsening fever, chills, and cough despite therapy with oral antibiotics. Chest radiographs demonstrated migrating, peripheral upper lobe infiltrates. A CBC count demonstrated significant eosinophilia. At bronchoscopy, eosinophil-rich mucus was seen impacted throughout his bronchi. A transbronchial biopsy confirmed the diagnosis of eosinophilic pneumonia. Symptoms, eosinophilia, and radiographic abnormalities were reversed with cessation of duloxetine. This case report briefly reviews the diagnosis of drug-induced pulmonary infiltrates with eosinophilia (PIEs) and eosinophilic pneumonia. To our knowledge, this is the first reported case of PIEs due to duloxetine.     

Chronic eosinophilic pneumonitis due to the inhalation of aerosolized face lotion: A case report

Rationale:Inhalation of toxic agents can induce eosinophilic pneumonia. However, only a few case reports demonstrate that exposure to materials can induce chronic eosinophilic pneumonia (CEP). Here, we describe a rare case of CEP with mild alveolar hemorrhage due to the inhalation of aerosols from face lotion. This is the first report of eosinophilic pneumonia caused by face lotion exposure.Patient concerns:A 39-year-old woman was admitted to our hospital with cough and dyspnea for 2 months, which coincided when she started to use a new aerosolized face lotion. Laboratory findings showed high blood eosinophil levels, and chest computed tomography (CT) scans revealed bilateral peripheral consolidation and ground-glass opacity mainly in the left upper lobe. She underwent flexible bronchoscopy. Eosinophils in bronchoalveolar lavage fluid (BALF) were slightly elevated, and the gross appearance of BALF was bloody. The histological examination of the transbronchial lung biopsy showed infiltration of eosinophils and macrophages in alveolar septa with edema and without vasculitis and granuloma formation; a small number of hemosiderin-laden macrophages were also observed. An inhalation challenge test involving the face lotion was performed. Six hours after the test, the blood test showed an increased white blood cell (WBC) count, and chest radiography showed slight exacerbation. Forced vital capacity decreased the following day.Diagnosis:According to histological analysis and positive result of an inhalation challenge test, she was diagnosed with CEP with mild alveolar hemorrhage due to inhalation of aerosols from the face lotion.Interventions and outcomes:She gradually improved without medication after stopping the use of face lotion.Lessons:To the best of our knowledge, this is the first report of CEP with mild alveolar hemorrhage due to the inhalation of face lotion. Various inhaled agents, such as face lotion, can induce CEP in rare cases.     

Idiopathic bronchiolitis obliterans organizing pneumonia (idiopathic BOOP) in childhood

Idiopathic bronchiolitis obliterans organizing pneumonia (idiopathic BOOP) is a clinicopathological entity of unknown origin first described by Epler and colleagues in 1985. We report our findings from a study of two Japanese boys aged 12 and 13 years with idiopathic BOOP. The patients showed no respiratory symptoms nor signs of infection. There was no history of exposure to noxious agents or medications in either case. Laboratory data, including hematological, biochemical, and immunological tests, were normal, and pulmonary function tests showed only a slight nonprogressive decrease from normal predicted values in vital capacity and diffusing capacity. Serial radiographs in both cases showed migration of patchy infiltrates. Fiberoptic bronchoscopy was performed for evaluation of eosinophilic pneumonia, but the bronchoalveolar lavage (BAL) revealed no increase in eosinophils and a decrease in CD4/CD8 ratio in the BAL fluid. Histopathological findings of transbronchial lung biopsy (TBLB) specimens were compatible with a diagnosis of BOOP. As neither case has shown clinical abnormalities apart from migratory patchy infiltrates on chest radiographs, both patients have been observed without drug therapy for 3–4 years. Pediatr Pulmonol. 1996; 22:67–72. © 1996 Wiley-Liss, Inc.     

Pranoprofen-induced lung injury manifesting as acute eosinophilic pneumonia]

A 48-year-old man was admitted to our hospital complaining of fever, dyspnea, and cough. He had been treated with pranoprofen and antibiotics by an outpatient clinic for the preceding 4 days. Chest X-ray films revealed Kerley B lines, perivascular cuffing, and hilar haze with pleural effusion in both lungs. Chest computed tomographic films showed non-segmental patchy infiltrates, and thickening of bronchovascular bundles and interlobular septa. Laboratory data showed eosinophilia in peripheral blood (28%) and severe hypoxemia (PaO2:60 torr). Bronchoalveolar lavage fluid disclosed an increased total cell count, eosinophils (39%), and CD 4/CD 8 ratio (2.1). Microscopic examination of transbronchial lung biopsy specimens showed infiltration of eosinophils and mononuclear cells into alveolar wall's and spaces. Acute eosinophilic pneumonia was suspected on the basis of Allen's diagnostic criteria (N Engl J Med: 1989). After discontinuation of pranoprofen, the patient's clinical symptoms, laboratory data, and chest X-ray findings improved rapidly without steroid therapy. A leukocyte migration test (LMT) for pranoprofen was positive and a challenge test for smoking was negative. An environmental provocation test in the patient's home gave negative results. A challenge test for pranoprofen was not performed due to the lack of informed consent. Based on these findings, our diagnosis was pranoprofen-induced lung injury manifesting as acute eosinophilic pneumonia.     

A rare cause of pulmonary infiltrates one should be aware of: a case of daptomycin-induced acute eosinophilic pneumonia

We report a 69-year-old patient who developed fever and dyspnea 3 weeks after the initiation of daptomycin therapy for spondylodiscitis with lumbar epidural and bilateral psoas abscesses due to ampicillin- and high-level-gentamicin-resistant Enterococcus faecium. There was profound hypoxia and the chest X-ray showed extensive patchy infiltrates bilaterally. A bronchoalveolar lavage revealed 30% eosinophils and results of microbiological studies were normal. Daptomycin-induced eosinophilic pneumonia was diagnosed and the patient rapidly improved after the discontinuation of daptomycin and a brief course of prednisone. Increased attention must be paid to this rare but serious side effect of daptomycin.     

A case of pulmonary aspergillosis presenting pulmonary bulla and eosinophilic pneumonia

A rare case of a 25-year-old man with pulmonary aspergillosis is reported. Pulmonary bulla and eosinophilic pneumonia in the right upper lobe were diagnosed by chest roentgenogram and transbronchial lung biopsy. Because the patient developed infective bullae during steroid therapy, we performed transcutaneous thoracic drainage and right upper lobectomy. The resected lung tissue contained numerous hyphae of Aspergillus. Around the hyphae of Aspergillus, granulomatous reaction and eosinophilic infiltration were observed. Antibodies against Aspergillus were detected in the serum of the patient. The number of peripheral blood eosinophils decreased after right upper lobectomy. These findings suggest that pulmonary bullae and eosinophilic pneumonia may be a rare manifestation of pulmonary aspergillosis.     

Ultrastructural observation of eosinophils in bronchoalveolar lavage fluid in eosinophilic pneumonia]

To investigate the morphological changes of local eosinophils in the lungs, we observed the ultrastructure of eosinophils in bronchoalveolar lavage fluid (BALF) from patients with eosinophilic pneumonia. We also measured the BALF concentration of eosinophil cationic protein (ECP) as an index of the activation of eosinophils. The eosinophils in BALF from patients with eosinophilic pneumonia showed various ultrastructural changes compared to eosinophils in BALF of the control patient. Changes included degranulation or disintegration of specific granules, cytoplasmic vacuolation, increased lipid droplets and the appearance of Charcot-Leiden crystals. These changes of BALF eosinophils were more prominent than those of peripheral blood eosinophils. ECP concentration (mean +/- SD) in BALF from patients with eosinophilic pneumonia was 12.2 +/- 7.78 micrograms/l which was significantly higher than the concentrations in patients with bronchial asthma not during an attack (1.36 +/- 2.08 micrograms/l) and in healthy control subjects (2.14 +/- 4.62 micrograms/l). These results suggest that local eosinophils in the lungs are activated and degranulated by various stimuli and undergo structural degeneration in eosinophilic pneumonia.     

A case of Paragonimus miyazakii with migrating infiltrates: use of ELISA in diagnosis and treatment]

A 47-year-old man was referred to our clinic with abnormal chest radiographs. He was free of symptoms, but his chest CT demonstrated transient migrating infiltrates. Peripheral blood revealed eosinophilia and eosinophilic pneumonia was suspected. However, the bronchoalveolar lavage fluid showed no increase in eosinophils. Later, the patient's pleural effusion did contain eosinophils. His total IgE level was continuously elevated despite the absence of allergic disease, and so parasitic infection was suspected. Ouchterlony's double diffusion test after absorption of Paragonimus westermanii antigen was positive for Paragonimus miyazakii antigen. The ELISA values of both serum sample and pleural effusion were increased. As the ELISA value of the pleural effusion was higher than the serum one, we realised that pleural effusion was caused by Paragonimus miyazakii. Treatment with praziquantel for 3 days resulted in disappearance of the abnormal chest radiographic findings, and a reduced blood eosinophil level, IgE level and ELISA titre for Paragonimus miyazakii. We concluded that ELISA was useful in the diagnosis and assessment for treatment in Paragonimus miyazakii infections although there was no clearly relevant history.     

Spherules, hyphae, and air-crescent sign

Coccidioidomycosis is endemic in the southwestern United States, resulting in 100,000 infections annually. The majority of these infections are asymptomatic or manifest as community-acquired pneumonia. In rare cases, patients can present with a mononuclear-cell predominant pyopneumothorax. The presence of spherules in tissue specimens is pathognomonic of this condition. A 72-year-old man born in Arizona with a heavy smoking history, presented with a 1-month history of weakness, night sweats, exertional dyspnea, and left pleuritic chest pain. The physical examination was remarkable for decreased breath sounds and dullness to percussion at the left lung base. His initial laboratory examination showed leukocytosis, eosinophilia, and elevated C-reactive protein. Computed tomography of the chest revealed a left lower lobe infiltrate, a cavity with air-crescent sign and hydropneumothorax. The pleural fluid was sampled and revealed an eosinophilic exudate with normal pH. Bacterial and fungal cultures of the pleural fluid were negative. Biopsy of the cavity wall showed chronic inflammation, fungal hyphae, and rare spherule-like structures. The surgical specimen culture grew Coccidioides immitis. Complement fixation for coccidioidomycosis performed on a serum sample was positive at a titer of 1:2 but a latex agglutinin test was negative. The patient was diagnosed with chronic fibrocavitary pneumonia with pyopneumothorax secondary to C. immitis infection and discharged on itraconazole for 1 year. Coccidioidomycosis can present in a variety of forms and should be part of the differential diagnosis in patients presenting with cavitation, air-crescent sign, eosinophilic pleural effusion, and hyphae and spherules on the tissue specimen. Chronic fibrocavitary pneumonia should be especially considered in patients who lived in endemic areas and have risk factors such as diabetes mellitus or pulmonary fibrosis related to smoking.     

A case of eosinophilic pneumonia induced by Pelex granule]

We report a case of eosinophilic pneumonia induced by Pelex granule. A 31-year-old male patient had been treated with Pelex granule and other drugs for common-cold symptoms such as cough and fever. Since these symptoms were persistent, he was admitted to our hospital for further examination. His laboratory findings showed eosinophilia and a mild elevation of serum IgE. Chest radiography revealed a reticular shadow and patchy shadows in both lung fields. Analysis of the bronchoalveolar lavage fluid (BALF) showed an increased percentage of eosinophils. The histological findings of the specimen obtained by transbronchial lung biopsy showed infiltration of eosniophils into the alveolar walls and spaces. After withdrawal of all drugs, the patient's clinical findings-symptoms, laboratory data, and chest radiographic findings-soon improved. A lymphocyte stimulation test (LST) for Pelex granule was positive. Taken together, the case was diagnosed as eosinophilic pneumonia induced by Pelex granule.