History : 67 year old male, non smoker, presents with over a month history of fevers, chills, anorexia and malaise despite antibiotic treatment for presumptive diagnosis of community acquired pneumonia by GP Case of the Month 7 January 2016

Case of the Month 7

What is your diagnosis? Case of the Month 7

Question: What are the key findings on this chest radiograph? Case of the Month 7

Answer: Bilateral air-space consolidation Subpleural, peripheral and upper lobe distribution Case of the Month 7

Question: What are the key findings on the CT images on lung windows? Case of the Month 7

Answer : Bilateral air-space consolidation with air-bronchograms Peripheral and subpleural Upper lobe predominant Case of the Month 7

Question: What are the key findings on the CT images on mediastinal windows? Case of the Month 7

Case of the Month Question: Bilateral hilar and mediastinal adenopathies

Additional clinical information: Previously healthy except for adult onset asthma Meds: Ventolin Allergies: Ragweed WBC: 14.1 with eosinophilia 3.2 BAL: 72% eosinophils Case of the Month 7

Before treatmentAfter treatment Case of the Month 7

What is your diagnosis? Case of the Month 7

Answer: Chronic Eosinophilic Pneumonia Case of the Month 7

 Idiopathic condition characterized by chronic infiltration of the lung by eosinophils  Epidemiology History of asthma or atopy in 50% 90% of patients are nonsmokers (smoking may be protective) Peak incidence in 5 th decade F>M, 2:1 Chronic Eosinophilic Pneumonia Discussion Case of the Month 7

 Symptoms: Insidious onset of fever, malaise, weight loss, and dry cough  Labs: Peripheral blood eosinophilia Eosinophilia in bronchoalveolar lavage ~>40% (normal is <1%) Chronic Eosinophilic Pneumonia Discussion Case of the Month 7

 CXR: Peripheral consolidation involving mainly the upper lobes “Photographic negative of pulmonary edema”  CT: Peripheral consolidation and/or GGO Upper lobe predominance Bilateral but can be asymmetric Septal thickening Chronic Eosinophilic Pneumonia Discussion Case of the Month 7

 CT – LESS COMMON FINDINGS: Centrilobular nodules Air-space nodules “Crazy paving pattern” Streaky or band-like opacities – (more often during improvement) Reactive mediastinal/hilar lymphadenopathy has been described Pleural effusions <10% Chronic Eosinophilic Pneumonia Discussion Case of the Month 7

Differential Diagnosis Chronic Eosinophilic Pneumonia Authors: Danielle Walker and Anastasia Oikonomou  Simple pulmonary eosinophilia (Loeffler syndrome) Minimal or no pulmonary symptoms Migratory opacities Resolves spontaneously  Churg-Strauss Lobular distribution of consolidation Frequently associated with centrilobular nodules and ground glass opacity  Organizing Pneumonia Nodules and masses, reticular opacities, non-septal lines, bronchodilation more common Peribronchial distribution more common Lower vs upper lung zone Not as strongly associated with eosinophilia, BAL usually shows more lymphocytes Differential Diagnosis Case of the Month 7

 Treatment: Dramatic response to corticosteroids  Prognosis: Recurrence/relapse in >80% of patients after steroid withdrawal Chronic Eosinophilic Pneumonia Discussion Case of the Month 7

Jeong YJ, Kim KI, Seo IJ et al. Eosinophilic lung diseases: a clinical, radiologic, and pathologic overview. Radiographics 2007;27: Mayo JR, Muller NL, Road J et al. Chronic eosinophilic pneumonia: CT findings in six cases. AJR 1989;153:727–30 Johkoh T, Muller NL, Akira M, et al. Eosinophilic lung diseases: diagnostic accuracy of thin-section CT in 111 patients. Radiology 2000;216:773–80 Kim Y, Lee KS, Choi DC et al. The spectrum of eosinophilic lung disease: radiologic findings. J Comput Assist Tomogr 1997;21: Arakawa H, Kurihara Y, Niimi H et al. Bronchiolitis obliterans with organizing pneumonia versus chronic eosinophilic pneumonia. AJR 2001;176: Marchand E, Reynaud-Gaubert M, Lauque D et al. Idiopathic chronic eosinophilic pneumonia. A clinical and follow-up study of 62 cases. Medicine 1998; 77: Chronic Eosinophilic Pneumonia Further Reading Authors: Danielle Walker and Anastasia Oikonomou Toronto, Canada