ZSFG report pearls 7/11/16 – Acute Eosinophilic pneumonia

First of all – I want to acknowledge that it’s been devastating week in this country. I will post separately about the UCSF response to the deaths of two unarmed black men and 5 police officers in Dallas. More on that to come.  
Thank you to Evie Kalmar for bringing a case of a 71 y/o woman with advanced dementia who was found to have acute eosinophilic pneumonia  with an absolute eosinophil count of 7500.  Massive gratitude to our brand new pulm fellow Chris Berger for dropping knowledge about chest xrays, eosinophils, and helminthes.
Pulled from the Blog archives (ZSFG report pearls 4/20/16), an overview of hypereosinophilia
  • Eosinophilia is an absolute eos count >500. It is divided into mild (500-1500), moderate (1500-5000) and severe (>5000)
    • Organ damage can occur at any elevation and work up is indicated for anyone symptomatic with eos >500 or asymptomatic with eos >1500 on 2 occasions.
  • There are many etiologies, but the major categories are:
    • Allergic – atopy, med allergy, ABPA
    • Infectious – helminths, some fungal infections
    • Heme/neoplastic – primary hypereosinophilic syndrome, leukemia, lymphoma, mastocytosis
    • Inflammatory/Immune – some immunodeficiencies, transplant rejection, asthma and eosinophilic invasion of organs (like eosinophilic pneumonia or esophagitis)
    • Endocrine – adrenal insufficiency
    • Rheumotologic
Acute Eosinophilic pneumonia basics
  • defined as acute febrile illness + hypoxemia + eosinophils on BAL (>25%) + bilateral CXR infiltrates
  • Can be primary (as in this patient) or secondary to…
    • Medications
      • Nitrofurantoin , Phenytoin , L-tryptophan , Ampicillin , Minocycline, Acetaminophen ,Inhaled pentamidine isethionate, Ranitidine, GM-CSF, Oxaliplatin
      • toxic ingestions/exposures
        • trazedone overdose, heroin or cocaine inhalation, inhalational injury after building collapse, inhalation of scotch guard
    • infections
      • HIV-associated
      • parasites (especially toxocara, filaria, Strongyloides, Ascaris, and Paragonimus)
      • fungi
      • transplant associated: aspergillus, coxackie A2 virus, stenotropomonas
    • inflammatory conditions
      •      Guillain-Barre syndrome, Vasculitis
    • neoplasms
      •      CML, primary hypereosinophilic syndrome, leukemias and lymphomas
Workup and management
  • goal is to exclude an underlying cause, provide supportive care for respiratory failure and give disease specific treatment
  • Steroids
    •     For intubated patients with primary eosinophilic pneumonia 1-2mg/kg q6h IV methyl pred is recommended
    • For non-intubated patients,
Last but not least, two pearls from Lisa Winston
  • Consider strongyloides hyperinfection syndrome in someone with unexplained gram negative sepsis who has recently received immunosuppression of some kind. In this entity, eosinophilia is usually modest.
  • Consider eosinophilic pneumonia in a patient with recurrent pneumonia that does not respond (or responds marginally) to antibiotics.
Sources:
Rhee CK, Min KH, Yim NY, Lee JE, Lee NR, Chung MP, Jeon K.  Clinical characteristics and corticosteroid treatment of acute eosinophilic pneumonia.
Simon D1, Wardlaw A, Rothenberg ME.Organ-specific eosinophilic disorders of the skin, lung, and gastrointestinal tract. J Allergy Clin Immunol. 2010 Jul;126(1):3-13; Eur Respir J. 2013;41(2):402.
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