1. Eosinophilic Pneumonia
Abdalmohsen Ababtain
Senior Resident
Saudi Board for Emergency Medicine
March 31st 2013
Supervised by :
Dr Ghassan Alghamdi

2. Case
 19 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)

3. Exam
 T 36.8 P:122 BP 120/65 RR
30
 SpO2 79% RA
 Patient looks in Respiratory Distress
 In Tripod Position
 Equal Bilatral Airentry
 No Wheeze, No Stridor nor drooling

5. Labs
 WBC 25.6 (mostly Nuetrophilic)
 Lactate 12.3
 Urine Tox Negative
 BG :
 PH 7.27 Co2 30 Po2 85 Hco3
14

6. In ER
 Asthma Management Started In ER
 Patient continue to Deteriorate
 Tubed !
 HIGH Peak and Airway Pressure !

7. In ICU
 H1N1 & Influenza & Parainfluenza and
AFB Negative
 Lactate started to Normalized
 BAL Done and ShowedEos 14%
Acute Eosinophilic Pneumonia
!!!

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12. Eosinophilic Lung Diseases
 Group 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

13. Eosinophilic Lung Diseases
 Acute Eosinophilic Pneumonia (AEP)
 Chronic Eosinophilic Pneumonia (CEP)
 Helminthic Infections (Löffler's syndrome)
 Non-Helminthic Infection (Coccidioidal
infection)
 Medications (NSAID)
 Toxins
 Churg-Strauss Syndrome
 Allergic Bronchopulmonary Aspergellousis
(ABPA)

14. Toxins
 Scorpion stings
 Inhalation of heroin or crack cocaine
 Inhalation of organic chemicals during
rubber manufacture
 Inhalation of dust or smoke
 Abuse of 1,1,1-trichloroethane
(Scotchguard)

15. Acute eosinophilic pneumonia
 Acute febrile illness with
 Severe hypoxaemia,
 Diffuse pulmonary infiltrates
 Increase in bronchoalveolar lavage
(BAL) eosinophils
 No evidence of infection or Drug
ingesion

16.  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: 1174–1180
JAMA 2004; 292:2997–3005

18. Inhalational exposures
associated with AEP
 Smoke (Most common specially first
time)
 Passive smoking* !!
 World Trade Center demolition dust
 Firework
 Tear gas bomb explosion
 Gasoline tank cleaning
 Cave exploration
 Woodpile moving
Chest 2000;117:277–279
*Allergology International. 2010;59:421-423

19. Approach
History :
 Chief complain and Associated symptoms
 Medication
 Chemical and occupational Exposure
(NSAID, Dust, Smoke)
 Travel Hx (Fungal inf.)
 Respiratory Hx (Asthma)
 Extrapulmonary Involvment

20. Physical Exam
 Fever
 Tachypnea
 Bibasilar inspiratory crackles or could
be clear in 20% of Patients
 Hypoxemic respiratory insufficiency is
frequently identified at presentation
and often requires mechanical
ventilation
Semin Respir Crit Care Med. 2006 Apr;27(2):142-7.

21. Labs
 Patients generally present with an initial
neutrophilic leukocytosis
 Blood eosinophilia, However, the
absence of it does not exclude these
conditions.
 Any concomitant glucocorticoid therapy
will suppress blood eosinophilia
 The magnitude of blood eosinophilia
is not a reliable means to distinguish the
possible etiologies of pulmonary
eosinophilia.
 High ESR !

22. Imaging
 At the Start, Subtle reticular or ground
glass opacities, often with Kerley B
lines
 Small pleural effusions are common

23. Imaging
 High 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

24. Eur Respir J 2013; 41: 402–409

25. BAL

26. Biopsy
 If BAL is not Revealing
 Biopsy, via a transbronchial or open
lung biopsy or VATS approach
depending upon the clinical and
radiographic findings

27. Cultures
 If there have been appropriate
geographic exposures for
coccidioidomycosis or clinical and
radiographic findings suggestive of
ABPA, fungal cultures should be
obtained

28. AEP is a diagnosis of exclusion
and Requires :
 An acute febrile illness of short duration
(usually less than one week)
 Hypoxemic respiratory failure
 Diffuse pulmonary opacities on chest
radiograph
 BAL eosinophilia >25 percent
 Lung 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.

29. Treatment
1. 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 AEP
Regimens :
 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

30. After Improvment
Continue oral prednisone in a dose of
40-60 mg per day for 2-4 weeks
2. Supportive Therapy
3. Smoking Cessation

31. Recurrence
 Relapse is uncommon and is usually
associated with resumption of
cigarette smoking after initial
cessation

32. Refrences
 Up to date
 Eur Respir J 2013; 41: 402–409
 Chest 2008; 133: 1174–1180
 JAMA 2004; 292:2997–3005
 Chest 2000;117:277–279
 Semin Respir Crit Care Med. 2006
Apr;27(2):142-7.

33. Thank You