RadiologyRadiology08/12/2009 08/25/2009

RadiologyRadiology

08/12/2009 08/26/2009

Eosinophilic Lung Disease: Eosinophilic Lung Disease: A case of drug-induced A case of drug-induced

eosinophilic pneumonitis.eosinophilic pneumonitis. Eldesia GrangerEldesia GrangerMarch 2, 2010March 2, 2010

MP-2MP-2

Eosinophilic Lung Eosinophilic Lung DiseaseDisease

Definition: a heterogeneous group of Definition: a heterogeneous group of disorders defined by increased numbers disorders defined by increased numbers of eosinophils within the pulmonary of eosinophils within the pulmonary parenchyma.parenchyma.

Defining characteristics:Defining characteristics: Peripheral blood eosinophilia with radiographically Peripheral blood eosinophilia with radiographically

identified pulmonary abnormalities.identified pulmonary abnormalities. Lung parenchyma eosinophilia demonstrated in Lung parenchyma eosinophilia demonstrated in

transbronchial or open lung biopsies .transbronchial or open lung biopsies . Increased eosinophils in bronchoalveolar lavage Increased eosinophils in bronchoalveolar lavage

(BAL) fluid (BAL) fluid

Eosinophilic Lung Disease: Eosinophilic Lung Disease: Differential Diagnosis: Primary Differential Diagnosis: Primary

CausesCauses

Primary (Idiopathic)Primary (Idiopathic) Churg–Strauss syndrome: Churg–Strauss syndrome: necrotizing necrotizing

vasculitis affecting small to medium sized vessels vasculitis affecting small to medium sized vessels associated with granulomatous inflammation associated with granulomatous inflammation involving the respiratory tract asthma, allergic involving the respiratory tract asthma, allergic rhinitis, and eosinophiliarhinitis, and eosinophilia

Hypereosinophilic syndromes: Hypereosinophilic syndromes: a group of

disorders marked by the sustained overproduction of eosinophils, in which eosinophilic infiltration and mediator release cause damage to lung, sinuses, nervous system, gastrointestinal tract, kidney, and heart . .

Eosinophilic Lung Disease: Eosinophilic Lung Disease: Differential Diagnosis: Primary Differential Diagnosis: Primary

CausesCausesAcute Idiopathic Acute Idiopathic Eosinophilic PneumoniaEosinophilic Pneumonia Usually less than 2 Usually less than 2

weeksweeks Increased risk for Increased risk for

smokerssmokers Male:female 1: 1Male:female 1: 1 Absent or low blood Absent or low blood

esosinophiliaesosinophilia Severe hypoxemiaSevere hypoxemia Diffuse Diffuse

alveolointerstitial alveolointerstitial patternpattern

Chronic: Idiopathic Chronic: Idiopathic Eosinophilic PneumoniaEosinophilic Pneumonia >> 1 month 1 month h/o asthmah/o asthma Mild respiratory Mild respiratory

distressdistress Marked blood Marked blood

eosinophiliaeosinophilia ESR and CRP ESR and CRP

increasedincreased Elevated IgEElevated IgE Male: female 1:2Male: female 1:2

Eosinophilic Lung Disease: Eosinophilic Lung Disease: Differential Diagnosis: Differential Diagnosis:

Secondary CausesSecondary Causes

SecondarySecondary Eosinophilic pneumonias of Eosinophilic pneumonias of

parasitic originparasitic origin Tropical eosinophilia.Tropical eosinophilia. Ascaris pneumoniaAscaris pneumonia Larva migrans syndromeLarva migrans syndrome Strongyloides stercoralis Strongyloides stercoralis

infectioninfection Allergic bronchopulmonary Allergic bronchopulmonary

aspergillosis and related aspergillosis and related fungal syndromesfungal syndromes

Drug, toxic agents and Drug, toxic agents and radiation-induced.radiation-induced.

Evaluation of Pulmonary Evaluation of Pulmonary EosinophiliaEosinophilia

History:History: Medication, Travel, Toxin Exposures, Medication, Travel, Toxin Exposures, Extra-pulmonary symptomsExtra-pulmonary symptoms

Blood eosinophiliaBlood eosinophilia Radiological Imaging with High Res. CTRadiological Imaging with High Res. CT

Johkoh et al found that the Johkoh et al found that the three eosinophilic lung diseases that could be diagnosed with greatest certainty were CEP, ABPA and AEP

BronchoscopyBronchoscopy >25% of BAL fluid is highly suggestive of pulmonary >25% of BAL fluid is highly suggestive of pulmonary

eosinophiliaeosinophilia SerologiesSerologies

CEP can occur in association with collagen vascular CEP can occur in association with collagen vascular disease, vasculitis, rheumatoid arthrities, scleroderma, disease, vasculitis, rheumatoid arthrities, scleroderma, Ulcerative colitis, breast cancer, and other neoplasms. Ulcerative colitis, breast cancer, and other neoplasms.

Drug-Induced Eosinophilic Drug-Induced Eosinophilic PneumonitisPneumonitis

DefinitionDefinition: Diagnosis of exclusion. Documentation of : Diagnosis of exclusion. Documentation of drug known to cause pulmonary eosinophilia. Rapid drug known to cause pulmonary eosinophilia. Rapid resolution with withdrawal of the drug and/or steroid resolution with withdrawal of the drug and/or steroid initiation.initiation.

Incidence: Currently unknown. Estimated 100-500 Incidence: Currently unknown. Estimated 100-500 cases/year.cases/year.

Well known epidemics: Well known epidemics: 1. L-tryptophan Eosinophila Myalgia Syndrome: 19891. L-tryptophan Eosinophila Myalgia Syndrome: 19892. Spanish Toxic Oil Syndrome 1981 2. Spanish Toxic Oil Syndrome 1981

Mechanism of ActionMechanism of Action

Offending AgentsOffending Agents Commonly reportedCommonly reported

1. nitrofurantoin1. nitrofurantoin2. gold salts2. gold salts3. captopril3. captopril4. minocycline4. minocycline5. NSAIDs5. NSAIDs6. methotrexate6. methotrexate

Occasionally reported Occasionally reported 1. captopril1. captopril2. sulfonamides 2. sulfonamides 3. GM-CSF3. GM-CSF

Rarely reported Rarely reported 1. Dapsone1. Dapsone2. chloroquine2. chloroquine3. diclofenac3. diclofenac4. erythromycin4. erythromycin5. INH5. INH6. NSAIDS6. NSAIDS7. Pyrimethamine7. Pyrimethamine8. ethambutol8. ethambutol

Drug-Induced Eosinophilic Drug-Induced Eosinophilic PneumonitisPneumonitis

TreatmentTreatment

1. withdrawal of offending agent1. withdrawal of offending agent

2. high dose steroids2. high dose steroids

Our patientOur patient

Started on high dose steroids.Started on high dose steroids. Peripheral Eosinophilia resolved in Peripheral Eosinophilia resolved in

24 hours.24 hours. ABG showed resolved hypoxiaABG showed resolved hypoxia Patient was discharged home on Patient was discharged home on

steroid taper. steroid taper. Suggested offending meds: Suggested offending meds:

minocycline, NSAIDS.minocycline, NSAIDS.

ResourcesResources

Allen JN ET AL. Drug-induced eosinophilic lung disease CLINICS IN CHEST MEDICINE 2004; 25: 77

Cottin, V, Cordier, JF. Eosinophilic pneumonias. ALLERGY 2005; 60:841.

Janz DR, O'Neal HR et al. Acute eosinophilic pneumonia: A case report and review of the literature . CRITICAL CARE MEDICINE APR 2009; 37:1470-1474.

Johkoh, T, Müller, NL, Akira, M, et al. Eosinophilic lung diseases: Diagnostic accuracy of thin-section CT in 111 patients. Radiology 2000; 216:773.

Katz U, Shoenfeld Y. Pulmonary eosinophilia CLINICAL REVIEWS IN ALLERGY & IMMUNOLOGY  2008; 34: 367-371   

Klion A Hypereosinophilic Syndrome: Current Approach to Diagnosis and Treatment. ANNUAL REVIEW OF MEDICINE 2009;  60: 293-306.

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