2. CLINICAL CASE PORTO, 25 FEBRUARY 2014
EVA PADRÃO, VANESSA SANTOS, PATRÍCIA CAETANO MOTA, NATÁLIA MELO, CONCEIÇÃO SOUTO MOURA, SUSANA GUIMARÃES, JOSÉ PEREIRA, RUI CUNHA, ANTÓNIO MORAIS
PORTO, 25 FEBRUARY 2014

3. identification JFSM Male gender 63 years-old Caucasian
Resident in Maia
Retired (occupation: glass fitter)

4. Past medical history Hypertension Dyslipidemia
Esophageal hiatus hernia
Surgery to left knee bursitis in 2010
Smoker (25 pack-years)
Allergy to ibuprofen; no other allergies documented
No drugs or alcohol consume; no sexual risk behaviours; no recent traveling abroad

5. usual medication Losartan/hydrochlorothiazide 50/12.5 mg id
Fenofibrate 200 mg id
Note:
Fenofibrate (initiated in September 2013) was suspended by patient initiative for some time due to development of skin reaction
Meanwhile, administration was resumed two weeks before seeking medical assistance

6. Main complaints
Fever
Myalgia
maculopapular rash

7. History of present illness
At the beginning of October 2013
fever, myalgia and sweating
medicated with amoxicillin/clavulanic acid and, subsequently, levofloxacin
2 weeks later
maintenance of complaints + appearance of skin rash on the trunk and limbs
hospitalized for monitoring and antibiotic treatment (usual medication stopped during this period)
discharged 8 days later with a diagnosis of community-acquired pneumonia

8. History of present illness
Chest X-ray by the time of admission, with left perihilar opacity and a micronodular pattern at the right lung base.

9. History of present illness
3 days after discharge
re-initiates fever, myalgia and pruriginous rash on inner thighs  hospitalized
usual medication was resumed

10. physical examination Oximetry (FiO2 21%): 98%
No signs of respiratory distress
Pulmonary auscultation: bilateral symmetric sounds with crackles in both lung bases
Maculopapular skin lesions on the trunk and limbs, most evident in the inner thighs and abdominal wall with dermographism
No other changes

11. Diagnostic test results
Blood analysis:
Normal hemoglobin
Mild leukocytosis [12.33x109/L (N 4-11x109/L)], with eosinophilia [18.2% – 2.24x109/L (N %)]
CRP mg/L

12. Diagnostic test results
Chest X-ray: heterogeneous left perihilar opacity and a micronodular pattern at the right lung base

13. Diagnostic test results
High-resolution Chest CT: peribronchovascular opacity most evident in the periphery of the LLL, associated with air bronchogram and slight thickening of the interlobular septa; bilateral discrete ground-glass micronodular pattern

14. Diagnostic test results
High-resolution Chest CT: peribronchovascular opacity most evident in the periphery of the LLL, associated with air bronchogram and slight thickening of the interlobular septa; bilateral discrete ground-glass micronodular pattern

15. Diagnostic test results
Bronchoscopy: without morphological or topographical
features
BAL: lymphocyte 6.4%, macrophages 83.8%, neutrophils 0.4%, eosinophils 9%, mast cells 0.4%; cytology negative for malignant cells, no microorganisms were found

16. Diagnostic test results
Transthoracic needle aspiration biopsy

17. Two adequate fragments of transthoracic biopsy

18. Expansion of alveolar septa by edema and a mixed inflammatory infiltrate
Organizing pneumonia lesions and pneumocyte hyperplasia

19. Prominent eosinophilic interstitial infiltrate, with some clustering; few within alvelar spaces

20. Diagnosis: Morphologic features of eosinophilic pneumonia (integrate in the clinical/radiologic context)

21. Diagnostic test results
Complementary blood analysis
IgE 737 kU/L (N < 114)
Sedimentation velocity 48 mm/1st h (N < 20)
Remaining immunological, autoimmune and serological study without abnormalities
Immunophenotyping of peripheral blood: T cells with abnormal expression of CD3; polyclonal B population
Bone marrow biopsy: reactive changes
Skin biopsy: chronic nonspecific epidermotropic dermatitis
Cultural tests (hemocultures, urine culture, stool examination, BAL, pulmonary biopsy): negative

22. Temporal relation with fenofibrate introdution
SUMMARY
FEVER
SKIN RASH
EOSINOPHYLIA
PULMONARY OPACTITIES
Temporal relation with fenofibrate introdution

23. Final diagnosis PROBABLE DRESS SYNDROME (associated with fenofibrate)
EOSINOPHILIC PNEUMONIA (in the context of fenofibrate?)

24. evolution Fenofibrate was stopped Subsequently resolution of symptoms
O doente só fez antiboterapia e parou fibrato. Não fez corticoterapia!
Marked regression of parenchymal consolidation areas, persisting mild residual features.

25. DISCONTINUATION OF FIBRATE

26. T cells with abnormal expression of CD3
evolution
February 2014
Clinical, radiological and analytical improvement
BLOOD ANALYSIS
OCTOBER 2013
FEBRUARY 2014
Normal Values
Hemoglobin
13.2 g/dL
15 g/dL
13-18
Leucocytes
12.33x109/L
6.88x109/L
4-11x109/L
Eosinophils
2.24x109/L (18.2%)
0.38x109/L (5,5%) %
Sedimentation velocity
48 mm/1st h
6 mm/1st h
0-20
CRP
132.9 mg/L
2.4 mg/L
< 3
IgE
737 kU/L
149 kU/L
< 114
Immunophenotyping
T cells with abnormal expression of CD3
Normal