acute eosinophilic pneumonia
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Eosinophilic PneumoniaAbdalmohsen AbabtainSenior Resident
Saudi Board for Emergency Medicine
March 31st 2013
Supervised by :Dr Ghassan Alghamdi
Case19 Years old Presented to ER with
SOB and Sore throat and fever for 2 Days after coming Back from Makkah
Has a Hx of atopy (SOB from Dust) with positive Family history too
He Started to smoke cigarettes a week ago (a cigarette/day)
ExamT 36.8 P:122 BP 120/65
RR 30SpO2 79% RA Patient looks in Respiratory
DistressIn Tripod PositionEqual Bilatral AirentryNo Wheeze, No Stridor nor
drooling
LabsWBC 25.6 (mostly Nuetrophilic)
Lactate 12.3Urine Tox NegativeBG :PH 7.27 Co2 30 Po2 85 Hco3
14
In ERAsthma Management Started In
ERPatient continue to Deteriorate Tubed ! HIGH Peak and Airway Pressure !
In ICUH1N1 & Influenza & Parainfluenza
and AFB NegativeLactate started to NormalizedBAL Done and Showed Eos
14%
Acute Eosinophilic Pneumonia !!!
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Eosinophilic Lung DiseasesGroup of Disorders with high
eosinophils in Lung Parenchyma The Defining Characteristics
include either:1. Peripheral Blood Eosinophilia
with Radiological Pulmonary Abnormality
2. Lung tissue eosinophilia in Biopsy
3. High eosinophils in BAL
Eosinophilic Lung DiseasesAcute Eosinophilic Pneumonia (AEP)Chronic Eosinophilic Pneumonia (CEP)Helminthic Infections (Löffler's syndrome)Non-Helminthic Infection (Coccidioidal
infection)Medications (NSAID)ToxinsChurg-Strauss SyndromeAllergic Bronchopulmonary Aspergellousis
(ABPA)
ToxinsScorpion stingsInhalation of heroin or crack
cocaineInhalation of organic chemicals
during rubber manufactureInhalation of dust or smokeAbuse of 1,1,1-trichloroethane
(Scotchguard)
Acute eosinophilic pneumoniaAcute febrile illness with
Severe hypoxaemia,Diffuse pulmonary infiltratesIncrease in bronchoalveolar
lavage (BAL) eosinophilsNo evidence of infection or
Drug ingesion
Less than 100 cases of AEP have been reported to date
The largest series including only 33 patients
An epidemiologic study of this disease identified 18 patients with AEP among183,000 US military personnel deployed in Iraq, all of them were smokers, with 78% of them recently beginning to smoke
Chest 2008; 133: 1174–1180JAMA 2004; 292:2997–3005
Inhalational exposures associated with AEPSmoke (Most common specially
first time)Passive smoking* !!World Trade Center demolition dustFireworkTear gas bomb explosionGasoline tank cleaningCave explorationWoodpile moving
Chest 2000;117:277–279*Allergology International. 2010;59:421-423
Approach
History :Chief complain and Associated
symptomsMedicationChemical and occupational Exposure
(NSAID, Dust, Smoke)Travel Hx (Fungal inf.)Respiratory Hx (Asthma)Extrapulmonary Involvment
Physical ExamFeverTachypneaBibasilar inspiratory crackles or
could be clear in 20% of PatientsHypoxemic respiratory
insufficiency is frequently identified at presentation and often requires mechanical ventilation
Semin Respir Crit Care Med. 2006 Apr;27(2):142-7.
LabsPatients generally present with an initial
neutrophilic leukocytosisBlood eosinophilia, However, the absence
of it does not exclude these conditions.Any concomitant glucocorticoid therapy
will suppress blood eosinophiliaThe magnitude of blood eosinophilia
is not a reliable means to distinguish the possible etiologies of pulmonary eosinophilia.
High ESR !
ImagingAt the Start, Subtle reticular or
ground glass opacities, often with Kerley B lines
Small pleural effusions are common
ImagingHigh resolution CT ground-glass
attenuation, airspace consolidation, poorly defined nodules.
The triad of • Interlobular septal thickening, • Bronchovascular bundle
thickening, and • Pleural effusions
are most suggestive AEP
Eur Respir J 2013; 41: 402–409
BAL
BiopsyIf BAL is not RevealingBiopsy, via a transbronchial or
open lung biopsy or VATS approach depending upon the clinical and radiographic findings
CulturesIf there have been appropriate
geographic exposures for coccidioidomycosis or clinical and radiographic findings suggestive of ABPA, fungal cultures should be obtained
AEP is a diagnosis of exclusion and Requires :An acute febrile illness of short duration
(usually less than one week)Hypoxemic respiratory failureDiffuse pulmonary opacities on chest
radiographBAL eosinophilia >25 percentLung biopsy evidence of eosinophilic
infiltrates (acute and/or organizing diffuse alveolar damage with prominent eosinophilia is the most characteristic finding)
Absence of known causes of eosinophilic pneumonia, including drugs, infections.
Treatment1. Glucocorticoid administration (preferably
after blood extraction) is medically indicated if:
Hypoxemia and in respiratory distress If the etiology is either AEP or a medication
or toxin-elicited AEPRegimens : In the absence of respiratory failure, initial
treatment is with oral prednisone (40 to 60 mg daily).
In the presence of respiratory failure, methylprednisolone (60 to 125 mg every 6 hours)
Optimal Duration is not yet clear (2-4 wks no diff)*
*Eur Respir J 2013; 41: 402–409
After Improvment
Continue oral prednisone in a dose of 40-60 mg per day for 2-4 weeks
2. Supportive Therapy3. Smoking Cessation
Recurrence Relapse is uncommon and is
usually associated with resumption of cigarette smoking after initial cessation
RefrencesUp to dateEur Respir J 2013; 41: 402–409Chest 2008; 133: 1174–1180JAMA 2004; 292:2997–3005Chest 2000;117:277–279Semin Respir Crit Care Med. 2006
Apr;27(2):142-7.
Thank You
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