Mechanisms of acute eosinophilic inflammation in a case of acute eosinophilic pneumonia in a 14-year-old girl

Acute Eosinophilic Pneumonia Secondary to Menthol Cigarette Use: A Rare Phenomenon With a Review of Literature

Idiopathic acute eosinophilic pneumonia (AEP) is a very rare disease with fewer than 200 cases reported. It has been hypothesized to be a hypersensitivity reaction to an unidentified antigen. The clinical presentation typically involves fever, nonproductive cough, shortness of breath, and bibasilar inspiratory crackles within the first week of antigen exposure. Chest imaging usually reveals bilateral reticular and/or ground-glass opacities. Bronchoalveolar lavage demonstrates >25% eosinophils. Corticosteroids are the mainstay of treatment with good results; however, optimum dose and length of treatment are unclear. We present a case of a 31-year-old male who presented with 2 days of shortness of breath, cough, pleuritic chest pain, fevers, chills, nausea, and poor appetite in the setting of initiation of menthol-flavored cigarettes 2 weeks before presentation. He rapidly progressed to respiratory failure requiring intubation despite broad antibiotic coverage. His course was complicated by severe acute respiratory distress syndrome, circulatory shock, and renal failure. He underwent bronchoalveolar lavage testing that revealed 60% eosinophils. He was treated with steroids and was subsequently extubated and discharged. Eosinophilic counts in the blood peaked on the 10th day of admission to 34%. One week later, the patient was completely free of symptoms. The initiation of menthol cigarette use in this patient is the likely reason for ensuing acute eosinophilic pneumonia, hence adding to the sporadic reports on the role of menthol-flavored cigarettes. This case emphasizes a greater reliance on risk factors, as opposed to eosinophilic markers, for the diagnosis and treatment of acute eosinophilic pneumonia to prevent subsequent respiratory failure and intubation in such patients.

Early diagnosis based on clinical history and BALF for successful management of smoking-induced acute eosinophilic pneumonia without unnecessary antibiotic usage: a case report

INTRODUCTION

Acute eosinophilic pneumonia (AEP) is a rapid onset and severe respiratory illness characterized by acute febrile respiratory insufficiency, eosinophilic infiltration in the lungs and unique findings on chest imaging. Difficulty in differentiating from other respiratory distress caused by community-acquired pneumonia may result in a delayed diagnosis or treatment with empirical antibiotics.

CASE STUDY

Sixteen-year-old boy who developed AEP with marked eosinophilia in bronchoalveolar lavage fluid (BALF, 36.6%), decreased diffusion capacity of the lung for carbon monoxide (62%) and unique radiological findings. Although he initially denied tobacco use, on repeated thorough clinical history questioning, he eventually admitted beginning smoking 19 days before the onset of symptoms with gradually increasing frequency.

RESULTS

His symptoms resolved quickly without use of antibiotics after cessation of tobacco and treatment with corticosteroids.

CONCLUSION

Careful clinical history taking regarding tobacco use combined with early examination of BALF and recognition of unique radiological findings are critical for proper management of AEP.

[Non allergic simple eosinophilic pneumonia--Löffler syndrome--a case report study]

INTRODUCTION

Löffler syndrome is an acute, pneumonia of unknown ethiology. This disease is not often associated with bronchial asthma. In its asymptomatic form, this disease is reversible, transient, self-limited with no requests for specific therapy regimen. In the symptomatic form, as well as during its progression, treatment with steroids is very effective. Furthermore, in both acute eosinophilic and idiopathic chronic eosinophilic form, this kind of therapy ensures survival.

CASE REPORT

The case of a 53-year-old Caucasian woman was presented with 2-month history of low grade fever, shortness of breath, cough and reduced exercise tolerance. Although she had an allergic accident on insects in history, non allergy reactions as well as an obstructive disease with that kind of origin were not detected on admission. The diagnosis of simple eosinophilic pneumonia (SEP) (Löffler's syndrome) was confirmed by transbronchial biopsy and by sternal testing. The peripheral blood eosinophilia with pulmonary eosinophilic infiltrates on X ray chest radiography were observed during clinical examination. Biopsy specimen of the lung parenchym showed changes associated with Löffler's syndrome. The diagnosis was, also, confirmed according to the radiographic findings of unilateral migratory infiltrates consistent pneumonia.

DISCUSSION

Churg Strauss syndrome (CSS) has to be considered in this differential diagnosis. Frequently, this disease has extrinsic bronchial asthma with eosinophilic pneumonia in history: asthma is often associated with allergic bronchopulmonary aspergillosis. In the reported case, treatment with steroids resulted in a marked clinical improvement compared to nonsteroid therapy.

Flavored Cigar Smoking Induces Acute Eosinophilic Pneumonia

Two cases of acute eosinophilic pneumonia (AEP) following smoking of flavored cigars were analyzed for characteristic features. None of our patients had a history of smoking flavored cigars/cigarettes in the past. One of them had never smoked, and the second patient was an ex-smoker who quit 17 years ago. Both patients presented with community-acquired pneumonia-like symptoms that did not respond to treatment with antibiotics. Their chest radiographs revealed bilateral diffuse infiltrates. The diagnosis of AEP was established based on the clinical picture, BAL that revealed an average eosinophil count > 45%, and immediate clinical improvement after introducing corticosteroids. All other possible causes were excluded during the initial workup.

Clarithromycin-induced eosinophilic pneumonia

Clarithromycin (CAM) has been widely used for the treatment of respiratory infection. Macrolides are generally well tolerated and their adverse reactions are rare. An 80-year-old woman with nontuberculous mycobacterium infection was treated with combined chemotherapy, including isoniazid, rifampicin, and ethambutol. She developed a fever and peripheral blood eosinophilia, and new subpleural consolidations were observed on chest radiography three days after add-on therapy with CAM. The symptoms and clinical findings improved with the withdrawal of CAM. Histopathologic examinations confirmed the diagnosis of eosinophilic pneumonia. This is the first report of CAM-induced eosinophilic pneumonia.

Chronic eosinophilic pneumonia: a case report and national survey

Few reports of chronic eosinophilic pneumonia (CEP) in the pediatric population can be found in the literature. Our patient, a 16-year-old male subject presenting with signs and symptoms of CEP, prompted a survey of pediatric pulmonary training centers in the United States to determine the prevalence of eosinophilic pneumonia. The survey showed a low prevalence of acute eosinophilic pneumonia and CEP in the pediatric population, with an overall male/female ratio of 1.6:1.

Cytokine abnormalities in a patient with eosinophilic fasciitis

BACKGROUND

Eosinophilic fasciitis (EF) and peripheral eosinophilia are rare in children.

OBJECTIVE

To describe a case of EF in a 3-year-old child who presented with acute painless induration of her forearm.

METHODS

Cytokine profiles were obtained and compared with patients with atopic disease during the acute presentation and after treatment with low-dose prednisone.

RESULTS

The patient's serum showed elevation of transforming growth factor beta1 and interleukin-5, which improved after treatment with low-dose prednisone.

CONCLUSIONS

The case suggests that patients with EF have cytokine abnormalities similar to atopic patients, but with a striking elevation of transforming growth factor beta1. The responsiveness of the clinical symptoms and cytokine profile to low dose prednisone supports treatment with low dose immunosuppressive therapy in this disorder.

Eosinophilic lung diseases

In the last 30 years studies have shown that the lungs have been the target of eosinophilic migration producing eosinophilic lung diseases (ELD) secondary to allergens, irritants, parasites, infections, antibodies and drugs. Specific diagnoses can be made by: (1) Peripheral blood eosinophilia and chest X-ray infiltrates. (2) Lung biopsy. (3) Bronchoalveolar lavage (BAL). In developing countries ELD are most frequently associated with parasitic infection. This paper defines, classifies and presents the clinical characteristics and treatment of these diseases with emphasis on parasitic lung problems.

Pleural fluid levels of interleukin-5 and eosinophils are closely correlated

BACKGROUND

The mechanisms responsible for the accumulation of eosinophils in pleural fluid are not fully understood. The purpose of this study was to evaluate the relationship between eosinophil accumulation and the levels of interleukin (IL)-5, IL-3, and granulocyte/macrophage colony-simulating factor (GM-CSF) in pleural effusions.

METHODS

We evaluated 30 patients with eosinophilic pleural effusions (eosinophil count > 10% nucleated cells in pleural fluid) and 10 patients with noneosinophilic pleural effusions. The patients with eosinophilic pleural effusions included 22 patients with post-coronary artery bypass graft surgery pleural effusions and 8 patients with eosinophilic pleural effusions caused by other causes. IL-5, IL-3, and GM-CSF in all pleural fluids were measured using enzyme-linked immunosorbent assay kits.

RESULTS

The mean level of IL-5 in eosinophilic pleural effusions (283.1 +/- 341.6 pg/mL) was significantly (p < 0.025) higher than that in the noneosinophilic effusions (28.2 +/- 19.0 pg/mL). The absolute eosinophil count and percentage correlated significantly with the level of IL-5 in all patients (r = 0.55, p < 0.001, and r = 0.54, p < 0.001, respectively). There was no significant correlation between IL-5 levels and RBC counts in all patients (r = 0.24, p > 0.05). GM-CSF and IL-3 levels were below the detectable range in all pleural fluids.

CONCLUSION

There is a significant relationship between the levels of IL-5 in pleural fluid and the total number and percentage of eosinophils in the pleural fluid. IL-5 seems to be related to the eosinophil accumulation associated with blood or air in the pleural space and other eosinophilic pleural effusions.