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acute eosinophilic pneumonia

Patient. 20 yo female presents with 3 days of fever, pleuritic chest pain, and SOBPreviously healthyNo medicationsJust started smoking last weekNo known drug or toxin exposureNo recent travel. From Pope-Harman, et al. Findings were similar on the right (sorry!). Arrows indicate Kerley B lines. .

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acute eosinophilic pneumonia

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    1. Acute Eosinophilic Pneumonia Annie Weinsoft, MS4 Radiology Spring 2007

    3. Patient 20 yo female presents with 3 days of fever, pleuritic chest pain, and SOB Previously healthy No medications Just started smoking last week No known drug or toxin exposure No recent travel

    4. Patient, cont. Both CXR and CT show: Diffuse ground glass opacities and areas of consolidation Septal/interlobular thickening Bilateral pleural effusions No e/o cardiac enlargement. CBC: Elevated WBC with left shift Bronchoalveolar lavage: 30% Eosinophils, no e/o infection Diagnosis?

    6. Acute Eosinophilic Pneumonia (AEP) AKA Idopathic Acute Eosinophilic Pneumonia Rare Acute febrile illness Tends to occur in young (ave 30 yo), previously healthy patients Often requires mechanical ventilation Resolves quickly with corticosteroids Some reports of spontaneous recovery

    7. AEP Criteria Acute onset of respiratory sx < 1 month (older criteria use 7 days) Bilateral diffuse infiltrates on CXR Severe hypoxemia PaO2 on RA < 60 PaO2/FiO2 < 300, or Or O2 sat on RA < 90% Lung eosinophilia (may or may not have peripheral eos, as well) > 25% on bronchoalveolar lavage, or Eosinophilic infiltration on lung bx (more invasive, probably unnecessary unless done for other reasons) Absence of known cause of lung eosinophilia Known causes include: infections, exposure to certain drugs, asthma Patients with exposure to smoke and/or inhaled dusts are not excluded from the diagnosis

    8. Eosinophilic Pneumonias AEP is within a spectrum of EP which also includes: Loffler Syndrome / Simple EP Chronic EP Churg-Strauss Syndrome Hypereosinophilic Syndrome

    9. Non-idiopathic pulmonary eosinophilias Numerous other causes, including: Parasitic infections Ascaris, larva migrans, strongyloides, etc. Fungal infections Bronchopulmonary aspergillosis, etc. Some bacterial/viral pneumonias Toxic exposures Local radiation therapy/exposure Asthma Eosinophilic bronchitis Lung transplant Paraneoplastic syndromes Sarcoidosis

    10. Possible associations with AEP Smoking, especially new-onset Military study (Shorr et al) of 18 patients in Iraq found a significant increased risk with new-onset cigarette smoking within 2 weeks-2 mo of illness Should we trust a study whose follow-up was done at Walter Reed? Predisposition toward allergic rhinitis 82% had allergic diathesis by RAST or skin testing in study by Hayakawa No correlation with Asthma (except in chronic EP) Exposure to inhaled dusts and/or other noxious substances No increased risk in military study, but other case series have noted several patients with recent exposures to substaces such as dust, smoke, wood particles, and/or tear gas. Significance of these exposures is unclear.

    11. Typical Appearance on Chest CT

    12. AEP Histologic Appearance Above (Pope-Harman): Septal edema, fluid in alveoli, eosinophis and macrophages infiltrating both septa and alveoli. Right (Mochimaru): Intra-alveolar fibrin deposition

    13. So, how do we recognize AEP? Consider it if you see: Severe, acute febrile pneumonia with radiographic appearance of hydrostatic/permeability edema Check lavage fluid for eosinophilia Rule out other causes (when reasonable) Unexpected eosinophilia on CBC, bronchoalveolar lavage, and/or lung biopsy Chararteristic history, such as new-onset cigarette smoking

    14. Treatment Most cases are non-fatal, with appropriate supportive care Recovery typically occurs in 1-2 weeks, with no recurrences Traditional treatment has been with systemic corticosteroids (no exact regimen established) Several reports of patients recovering spontaneously without steroids, though this remains somewhat controversial.

    15. The End

    16. References Cottin V, Cortier JF. Eosinophilic Pneumonias. Allergy 2005;60:841 Mochimaru H, et al. Clinicopathological differences between acute and chronic eosinophilic pneumonia. Respirology 2005;10:76 Pope-Harman AL, et al. Acute eosinophilic pneumonia: a summary of 15 cases and review of the literature. Medicine (Baltimore) 1996;75(6):334 Philit F, et al. Idopathic acute eosinophilic pneumonia: a study of 22 patients. Am J Respir Crit Care Med 2002;166:1235 Hayakawa H, et al. A clinical study of idopathic eosinophilic pneumonia. Chest 1994;105:1462 Kim Y, et al. The spectrum of eosinophilic lung disease: radiographic findings. J Comput Assist Tomogr 1997;21(6):920 Shorr AF, et al. Acute eosinophilic pneumonia among US military personnel deployed in or near Iraq. JAMA 2004;292:2997 Ketai LH, Godwin JD. A new view of pulmonary edema and acute respiratory distress syndrome. J Thorac Imaging 1998;13:147

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