Download Idiopathic eosinophilic pneumonia

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