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
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
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
17.
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
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.