1. Radiology
08/12/2009
08/25/2009

2. Radiology
08/12/2009
08/26/2009

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

8. 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

9. 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 .

10. 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

11. 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 =

12. 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.

13. 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 cases/year.
Well known epidemics:
1. L-tryptophan Eosinophila Myalgia Syndrome: 1989
2. Spanish Toxic Oil Syndrome 1981

14. Mechanism of Action

15. 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

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

17. 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.

18. 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:
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:   
Klion A Hypereosinophilic Syndrome: Current Approach to Diagnosis and Treatment. ANNUAL REVIEW OF MEDICINE 2009;  60:
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