Radiology 08/12/2009 08/25/2009

Radiology 08/12/2009 08/26/2009

Eldesia Granger March 2, 2010 MP-2 Eosinophilic Lung Disease: A case of drug-induced eosinophilic pneumonitis. Eldesia Granger March 2, 2010 MP-2

Eosinophilic Lung Disease Definition: a heterogeneous group of disorders defined by increased numbers of eosinophils within the pulmonary parenchyma. Defining characteristics: Peripheral blood eosinophilia with radiographically identified pulmonary abnormalities. Lung parenchyma eosinophilia demonstrated in transbronchial or open lung biopsies . Increased eosinophils in bronchoalveolar lavage (BAL) fluid

Eosinophilic Lung Disease: Differential Diagnosis: Primary Causes Primary (Idiopathic) Churg–Strauss syndrome: necrotizing vasculitis affecting small to medium sized vessels associated with granulomatous inflammation involving the respiratory tract asthma, allergic rhinitis, and eosinophilia 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: Differential Diagnosis: Primary Causes Acute Idiopathic Eosinophilic Pneumonia Usually less than 2 weeks Increased risk for smokers Male:female 1: 1 Absent or low blood esosinophilia Severe hypoxemia Diffuse alveolointerstitial pattern Chronic: Idiopathic Eosinophilic Pneumonia > 1 month h/o asthma Mild respiratory distress Marked blood eosinophilia ESR and CRP increased Elevated IgE Male: female 1:2

Eosinophilic Lung Disease: Differential Diagnosis: Secondary Causes Eosinophilic pneumonias of parasitic origin Tropical eosinophilia. Ascaris pneumonia Larva migrans syndrome Strongyloides stercoralis infection Allergic bronchopulmonary aspergillosis and related fungal syndromes Drug, toxic agents and radiation-induced. Tropical eosinophilia =

Evaluation of Pulmonary Eosinophilia History: Medication, Travel, Toxin Exposures, Extra-pulmonary symptoms Blood eosinophilia Radiological Imaging with High Res. CT Johkoh et al found that the three eosinophilic lung diseases that could be diagnosed with greatest certainty were CEP, ABPA and AEP Bronchoscopy >25% of BAL fluid is highly suggestive of pulmonary eosinophilia Serologies CEP can occur in association with collagen vascular disease, vasculitis, rheumatoid arthrities, scleroderma, Ulcerative colitis, breast cancer, and other neoplasms.

Drug-Induced Eosinophilic Pneumonitis Definition: Diagnosis of exclusion. Documentation of drug known to cause pulmonary eosinophilia. Rapid resolution with withdrawal of the drug and/or steroid initiation. Incidence: Currently unknown. Estimated 100-500 cases/year. Well known epidemics: 1. L-tryptophan Eosinophila Myalgia Syndrome: 1989 2. Spanish Toxic Oil Syndrome 1981

Mechanism of Action

Offending Agents Commonly reported 1. nitrofurantoin 2. gold salts 3. captopril 4. minocycline 5. NSAIDs 6. methotrexate Occasionally reported 1. captopril 2. sulfonamides 3. GM-CSF Rarely reported 1. Dapsone 2. chloroquine 3. diclofenac 4. erythromycin 5. INH 6. NSAIDS 7. Pyrimethamine 8. ethambutol

Drug-Induced Eosinophilic Pneumonitis Treatment 1. withdrawal of offending agent 2. high dose steroids

Our patient Started on high dose steroids. Peripheral Eosinophilia resolved in 24 hours. ABG showed resolved hypoxia Patient was discharged home on steroid taper. Suggested offending meds: minocycline, NSAIDS.

Resources 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. Uptodate.com UNC pharmacy UNC Pulmonary