Pulmonary eosinophilic syndromes

Acute eosinophilic pneumonia, chronic eosinophilia, Churg-Strauss syndrome, and the hypereosinophilic syndrome are pulmonary eosinophilic syndromes characterized by an increased number of eosinophils in peripheral blood, in lung tissue, in sputum, in bronchoalveolar lavage fluid, or in all of these. These pulmonary eosinophilic syndromes generally are characterized by increased respiratory symptoms, abnormal radiographic appearance, and the potential for systemic manifestations. It is critical to exclude other causes of eosinophilia in patients who have lung disease, to make a quick diagnosis, and to treat aggressively with corticosteroids and other therapies to prevent long-term sequelae.     

Pulmonary infiltrates in immunosuppressed patients: analysis of a diagnostic protocol

A diagnostic protocol was started to study the etiology of pulmonary infiltrates in immunosuppressed patients. The diagnostic yields of the different techniques were analyzed, with special emphasis on the importance of the sample quality and the role of rapid techniques in the diagnostic strategy. In total, 241 patients with newly developed pulmonary infiltrates within a period of 19 months were included. Noninvasive or invasive evaluation was performed according to the characteristics of the infiltrates. Diagnosis was achieved in 202 patients (84%); 173 patients (72%) had pneumonia, and specific etiologic agents were found in 114 (66%). Bronchoaspirate and bronchoalveolar lavage showed the highest yields, either on global analysis (23 of 35 specimens [66%] and 70 of 134 specimens [52%], respectively) or on analysis of each type of pneumonia. A tendency toward better results with optimal-quality samples was observed, and a statistically significant difference was found in sputum bacterial culture. Rapid diagnostic tests yielded results in 71 of 114 (62.2%) diagnoses of etiological pneumonia.     

Pulmonary infiltrates in HIV-infected patients in the highly active antiretroviral therapy era in Spain

OBJECTIVE: To study the incidence, etiology, and outcome of pulmonary infiltrates (PIs) in HIV-infected patients and to evaluate the yield of diagnostic procedures. DESIGN: Prospective observational study of consecutive hospital admissions. SETTING: Tertiary hospital. PATIENTS: HIV-infected patients with new-onset radiologic PIs from April 1998 to March 1999. METHODS: The study protocol included chest radiography, blood and sputum cultures, serologic testing for "atypical" causes of pneumonia, testing for Legionella urinary antigen, testing for cytomegalovirus antigenemia, and bronchoscopy in case of diffuse or progressive PIs. RESULTS: One hundred two episodes in 92 patients were recorded. The incidence of PIs was 18 episodes per 100 hospital admission-years (95% confidence interval [CI]: 15-21). An etiologic diagnosis was achieved in 62 cases (61%). Bacterial pneumonia (BP), Pneumocystis carinii pneumonia (PCP), and mycobacteriosis were the main diagnoses. The incidences of BP and mycobacteriosis were not statistically different in highly active antiretroviral therapy (HAART) versus non-HAART patients. The incidence of PCP was lower in those receiving HAART (p =.011), however. Nine patients died (10%). Independent factors associated with higher mortality were mechanical ventilation (odds ratio [OR] = 83; CI: 4.2-1,682), age >50 years (OR = 23; CI: 2-283), and not having an etiologic diagnosis (OR = 22; CI: 1.6-293). CONCLUSIONS: Pulmonary infiltrates are still a frequent cause of hospital admission in the HAART era, and BP is the main etiology. There was no difference in the rate of BP and mycobacteriosis in HAART and non-HAART patients. Not having an etiologic diagnosis is an independent factor associated with mortality.     

Pulmonary infiltrates in immunocompromised patients: diagnosis by cytological examination of bronchoalveolar lavage fluid.

Thirty pulmonary infiltrates in 26 patients were investigated by bronchoalveolar lavage. Sixteen of the patients were on therapeutic immunosuppression for renal disease or transplant and 10 had leukaemia, lymphoma, or allied conditions. A rapid specific diagnosis was made in 21 (70%) episodes by cytological examination of the fluid and in 28 (93%) by a combination of cytology and microbiology. No complications from haemorrhage or pneumothorax ensued. Pneumonia due to Pneumocystis carinii was the most common diagnosis (27%), but opportunistic infections from cytomegalovirus, candida, aspergillus, zygomycetes, and acid fast bacilli were also identified by cytology. Two episodes were caused by occult pulmonary haemorrhage and five patients had malignant infiltration of the lung from leukaemia, myeloma, Hodgkin's disease, and lymphoplasmacytoid lymphoma. In two of these there was also evidence of infection. In seven cases with non-diagnostic cytology infections due to Staphylococcus aureus, Pseudomonas aeruginosa, pneumococcus, micrococcus, and Aspergillus fumigatus were identified on culture. In two patients (7%) no specific diagnosis was established by lavage: one had serological evidence of legionella infection and the second had P aeruginosa septicaemia. Twelve (75%) of the renal patients and six (60%) of those with leukaemia, lymphoma, and allied conditions recovered.     

Rapidly changing pulmonary infiltrates

Pulmonary eosinophilia responds very quickly to steroid treatment. Chronic pulmonary eosinophilia is common in middle aged females. We report on a patient who presented with subacute onset of shortness of breath, severe weight loss associated with a rise in the peripheral eosinophil count. She was treated successfully with steroids resulting in complete resolution of the pulmonary infiltrates.     

Pulmonary angiitis with atypical lymphoreticular infiltrates in Wiskott-Aldrich syndrome: possible relationship of lymphomatoid granulomatosis and EBV infection

We describe a 12-year-old boy with Wiskott-Aldrich syndrome who developed a pulmonary vasculitis associated with lymphoreticular proliferation, consistent with the histological and clinical diagnosis of lymphomatoid granulomatosis. The lesions were responsive to cyclophosphamide and steroids. The patient has had severely depressed immune function and was shown to have abnormal Epstein-Barr virus (EBV)-specific cellular and humoral immune responses. Lymph nodes obtained at autopsy were positive for EBV genome. In this patient, reactivated EBV infection resulting from impaired immune surveillance of the virus may have been responsible for the development of this paraneoplastic disorder.     

Lipomatous infiltrates of the heart

Fatty masses of the heart usually arise in the interatrial septum and are uncommon. The autopsy files from LAC-USC Medical Center contain 15 such cases from 1952 through 1972. Although these masses are yellow and attain a large size, most are considered to represent lipomatous infiltrations rather than true lipomas since they usually lack encapsulation and do contain cardiac muscle in varying amounts. The lesion is most often associated with obesity. Surprisingly, even the large masses produce few clinical symptoms and none was suspected clinically, each being an incidental finding at necropsy. However, these masses do infiltrate the conduction system and can cause arrhythmias and sudden death. Echocardiography or other noninvasive techniques may bring attention to a lipomatous mass that may or may not be asymptomatic. This can result in a clinical dilemma in differential diagnosis and treatment since myxomas, rhabdomyomas, and sarcomas also arise in the interatrial septum.     

Pulmonary eosinophilic response to respiratory syncytial virus infection in mice sensitized to the major surface glycoprotein G.

To investigate the contribution of immunity to individual respiratory syncytial (RS) virus proteins to the augmentation of pulmonary pathology, mice were scarified with recombinant vaccinia viruses (rVV) expressing individual RS virus proteins. The pulmonary response to infection with RS virus was monitored by bronchoalveolar lavage (BAL). In mice vaccinated with the major surface glycoprotein (G), 14-25% of BAL cells were eosinophils; these comprised less than 3% of BAL cells from other groups of mice after RS virus challenge. Mice sensitized to the G or fusion (F) proteins developed lung haemorrhage and those sensitized to G, F or nucleoprotein (N) showed pulmonary polymorphonucleocyte efflux. To investigate the concomitant changes in local T-cell subsets, BAL cells were stained with mAbs to CD4, CD8, CD45RB, alpha beta and gamma delta T cell receptor (TCR) proteins. Three colour flow cytometry showed that most cells were CD3+CD4+ alpha beta+gamma delta+ or CD3+CD8+ alpha beta+gamma delta-, although some CD4-CD8-SIg- cells were also identified. Most of these 'null' cells lacked CD3, but CD3+ null cells from rVV-G or -F primed mice bore either alpha beta and gamma delta TCR in approximately equal numbers. The intensity of staining for CD45RB declined rapidly after infection with RS virus on both CD4 and CD8 cells. The rate of loss of CD45RB on CD4 T cells was accelerated by prior sensitization with rVV-G, consistent with conversion to helper T cell subsets producing eosinophil-promoting cytokines. The eosinophilic reaction to RS virus infection therefore specifically reflects sensitization to G protein, but sensitization to other proteins can also cause distinct pathological effects.(ABSTRACT TRUNCATED AT 250 WORDS)