1. Pulmonary Eosinophilias & Vasculitides
Prof. Dr. Abdul Hameed Al Qaseer

2. Pulmonary Eosinophilias :
They are a group of disorders of different etiologies in which lesions in the lungs produce a chest x- ray asso-
ciated with pulmonary eosinophilia , with or without a
peripheral blood eosinophilia.

3. Causes : Extrinsic ( causes known ):
1. Helminths e.g. Ascaris , Toxocara ,Filaria .
2. Drugs : Nitrofurantoin , PAS , Sulfasalazine ,aspirin , imipramin , tetracycline , sulphonamides ,
penicillin , nalidixic acid , chlorpropamide, phenyibutazone ………
3. Fungi : e.g. Aspergillus fumigatus causing allergic
bronchopulmonary aspergillosis ABPA .

4. B. Intrinsic ( cause unknown ):
1. Cryptogenic eosinophilic pneumonia .
2. Churg – Strauss syndrome .
3. Hypereosinophilic syndrome .
4.Polyarteritis nodosa .

5. Allergic bronchopulmonary Aspergillosis ABPA
ABPA is caused by a hypersensitivity reaction to A. fumigatus involving the bronchial wall & peripheral part
of the lung .
It is associated with asthma .
Clinical Features :
Fever , SOB ,productive cough ( cast) & worsening asthma.
ABPA may lead to bronchiectasis .

6. Investigations :
CXR : Include transient diffuse pul. Infiltrate & lobar or segmental pul. Collapse .
Bronchiectasis ( tram-line, ring & gloved-finger shadows) predominantly in the upper lobes.
Positive skin test to A. fumigatus .
Elevated total IgE > 1000 ng /ml .
Elevated serum IgE- A. fumigatus or IgG A. fumigatus .
Blood eosinophilia > 0.5 x 109 / L .
Fungal hyphae of A. fumigatus in the sputum.

7. Management of ABPA :
1.Prednisolone mg /d + physiotherapy
2. Bronchoscopy ( lavage) to remove impacted mucus.
3. Some advocate high –dose inhaled corticosteroids .
4. Therapy with itraconazole may be beneficial in some .

8. Acute Eosinophilic Pneumonia
It is a rare febrile illness of 5-7 days durations . It may lead to hypoxic respiratory failure . BAL demonstrates > 25% eosinophils . The condition responds to corticosteroids .
Chronic Eosinophilic Pneumonia
It presented with fever , night sweating , cough ,
Anorexia , & weight loss , of several weeks to months .

9. Cryptogenic Eosinophilic Pneumonia (Idiopathic E. P. )
It is presented with malaise , fever, SOB , & dry cough .
CXR shows bilateral ,peripheral & predominantly upper lobes .
Peripheral eosinophilia ( very high ) , high ESR , & total IgE ,BAL high eosinophils .
It responses to prednisolone mg /d shows dramatic response.

12. Hypereosinophilic Syndrome
It is characterized by the presence of eosinophilia ( > 1500 / ul ) for > 6 months , associated with signs & symptoms of multisystem organ dysfunction.
The heart may involved with tricuspid valve abnormality or endomyocardial fibrosis & res -
trictive , biventricular CMP .
Other organs include the lung , liver , spleen ,
skin , & CNS .
It associated with T- cell lymphoma .
Treatment : Corticosteroid + hydroxyurea .

13. Charg -Strauss syndrome (CSS)
It is a multisystemic vasculitic disorder that frequently involves the skin , kidney, & nervous system in addition to the lung .
Bronchial asthma almost found Fever& eosinophilia usually present at time asthma ease the illness may be fulminating unless treated.
Leukotriene - modifying agents has been associated with CSS .

14. Churg -Strauss Syndrome

15. Lung Diseases Due to Organic Dusts
Hypersensitivity Pneumonitis (HP)
( Extrinsic allergic alveolitis ):
HP result from inhalation of certain types of organic dust which rise to a diffuse immune reaction in the wall of the alveoli & bronchioles .
-Farmer lung is the term commonly used for HP
due to inhalation of antigen present in moldy hay
, such as thermophilic actinomyces , Micropolyspora faeni , & Aspergillus's species.
-HP first described in

16. Lung Disease Caused by Organic Dust

17. Clinical Features Of HP
1. Acute :After few hours of re-exposure to the dust , the patient complains flu- like symptoms ( fever , headache , myalgia , malaise ,dry cough & SOB. Chest exam.: end - inspiratory crackles
2. Subacute : Over a period of weeks marked by
cough & SOB & may progress to cyanosis .
3. Chronic : due to chronic low level of exposure .
The onset is often insidious with progressive SOB if undiagnosed the disease may progress
to cause severe respiratory disability , hypoxemia , pul. hypertension , cor pulmonale.
Clubbing of finger may be present.

18. Investigations CXR : diffuse micronodular shadowing (upper )
HRCT : in acute … bilateral areas of consolidation .
PFT : restrictive , low DLco , low Pa O2 ,& low PaCO2 .
Other : high ESR , CRP , RF , ….
BAL : marked lymphocytic alveolitis .
Provocative test
Lung biopsy .

19. Predictive factors in the identification of HP
Exposure to a known antigen .
Positive precipitating Ab .
Recurrent episodes of symotoms .
Inspiratory crackles .
Symptoms occurring 4-8 hs after exposure .
Weight loss .

20. Management of HP 1. Avoid exposure ( in some difficult to achieved )
Or using dust masks with appropriate filters may minimize exposure .
2. In acute cases prednisolone 40 mg /d for 3-4 weeks.
3. Treatment of underlying complications e.g. Oxygen therapy for hypoxia .

21. Drugs Induced Respiratory Diseases

23. It is caused by cotton dust inhalation .
Byssinosis
It is caused by cotton dust inhalation .
It causes interstitial infiltration ( Monday fever ) . &
acute bronchiolitis with generalized airway obstructions like asthma .
CXR usually normal .
Smoking aggravates it.

24. Lung Diseases Due To Inorganic Dust
In certain occupations , theinhalation of inorganic dust , fumes , or other noxious substances may give rise to specific pathological changes in the lungs.
Pneumoconiosis a diffuse pulmonary fibrosis due to prolonged exposure to inorganic dusts .
It is an occupational hazard , therfore a detailed ocupational history is essential .e.g.
Coal worker's pneumoconiosis ;
Asbestosis ; Silicosis .

25. Coal Worker's Pneumoconiosis
Prolonged inhalation of coal dust overwhelms the alveolar macrophages , which aggregate to form
Macules in or near the centre of the secondary pulmonary lobules ,& a fibrotic reaction ensues.
1. Simple coal worker's pneumoconiosis( SCWP):
This can be divided into 3 categories on CXR.
However, it does not cause symptoms or abnormal PFT .

26. 2. Progressive massive fibrosis ( PMF):
( complicated pneumoconiosis)
Large dense masses mainly in the upper lobes ,
Cavitations may occur & must be differentiated from TB ; carcinomas ; Wagener's disease .
PMF is associated with cough , sputum ( may be black , melanoptysis ) , & SOB .
This may progress to RF , RVF even after cessation of exposure .

27. Caplan's syndrome :rheumatoid arthritis & rounded fibrotic nodules 0
Caplan's syndrome :rheumatoid arthritis & rounded fibrotic nodules cm in diameters, these are mainly in the periphery of the lung fields.
Pathologically similar to rheumatoid nodule including central necrosis . It may occur in other types of pneumoconiosis .

28. Silicosis
It results from the inhalation of crystalline or free silica , usually in the form of quartz . Similar to coal worker's pneumoconiosis , with multiple 3-5
mm nodular opacities predominantly in the mid & upper zones & may coalesce .
Enlargement of the hilar glands with an egg-shell pattern of calcifications . Patient may at increased risk of TB ( silicotuberculosis ).
Silica is a highly fibrogenic & the disease is usually
progressive ( even when exposure ceases) .
Acute disease similar to alveolar proteinosis after intense exposure to very fine crystalline silica dust.

30. Asbestosis ( cont.) 3. Asbestosis : Pulmonary fibrosis ---SOB , finger
clubbing , similar to ILD. CXR usually confined to the lower 2/3 . Honeycombing with shaggy cardiac shadow .The condition seldom develops in less than 20 years after exposure.
Complication ; RF ,cor pul. Dx may need biopsy .
4.Bronchial carcinoma : 10 time higher risk , & more in smokers. Also laryngeal carcinoma .
5. Mesothelioma of the pleura : It may occur with trivial exposure to blue asbestos . Chest pain ,
& bloody effusion , Dx by biopsy .