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Zhou X, Yang G, Zeng X, Wang L, Xiang J, Zhao J, Chen X, Zhang L. Dupilumab and the potential risk of eosinophilic pneumonia: case report, literature review, and FAERS database analysis. Front Immunol 2024; 14:1277734. [PMID: 38259470 PMCID: PMC10801202 DOI: 10.3389/fimmu.2023.1277734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024] Open
Abstract
Eosinophilic pneumonia (EP) is a rare but noteworthy adverse effect linked to dupilumab, an interleukin-4 (IL-4) and IL-13 inhibitor used in the managing atopic diseases. The underlying mechanisms, potential predisposing factors, clinical characteristics, and optimal management strategies for dupilumab-induced EP remain unclear. We report a 71-year-old patient who developed acute EP after the first 600-mg dose of dupilumab. Eosinophils (EOSs) were also transiently increased (up to 1,600 cells/μl). After the acute EP was effectively treated with glucocorticoids, dupilumab treatment was continued. Rash, itching, and immunoglobulin E levels continued to decrease in the patient, and no further pulmonary adverse events occurred. We combined this case with a literature review of nine articles and analyzed data from 93 cases reported in the FDA Adverse Event Reporting System (FAERS) database of patients developing EP after dupilumab use. Our findings imply that dupilumab may induce EP, particularly in individuals over 45 years old, those with a history of respiratory diseases, and those who have previously used inhaled or systemic steroids. Vigilance is required, especially when there is a persistent elevation in peripheral blood EOSs during treatment. Although steroid treatment can effectively manage EP, more data are needed to determine the safety of resuming dupilumab treatment after controlling pneumonia.
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Affiliation(s)
- Xiyuan Zhou
- Institute of Dermatology and Venereology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology, Chengdu, China
| | - Ge Yang
- Institute of Dermatology and Venereology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology, Chengdu, China
| | - Xuemei Zeng
- Respiratory Department, Chengfei Hospital, Chengdu, China
| | - Lan Wang
- Operation and Management Department, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology, Chengdu, China
| | - Jing Xiang
- Outpaitent Department, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology, Chengdu, China
| | - Jinyu Zhao
- Education and Training Department, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology, Chengdu, China
| | - Xuejun Chen
- Institute of Dermatology and Venereology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology, Chengdu, China
| | - Lixia Zhang
- Institute of Dermatology and Venereology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology, Chengdu, China
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Cottin V. Eosinophilic Lung Diseases. Immunol Allergy Clin North Am 2023; 43:289-322. [PMID: 37055090 DOI: 10.1016/j.iac.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
The eosinophilic lung diseases may manifest as chronic eosinophilic pneumonia, acute eosinophilic pneumonia, or as the Löffler syndrome (generally of parasitic etiology). The diagnosis of eosinophilic pneumonia is made when both characteristic clinical-imaging features and alveolar eosinophilia are present. Peripheral blood eosinophils are generally markedly elevated; however, eosinophilia may be absent at presentation. Lung biopsy is not indicated except in atypical cases after multidisciplinary discussion. The inquiry to possible causes (medications, toxic drugs, exposures, and infections especially parasitic) must be meticulous. Idiopathic acute eosinophilic pneumonia may be misdiagnosed as infectious pneumonia. Extrathoracic manifestations raise the suspicion of a systemic disease especially eosinophilic granulomatosis with polyangiitis. Airflow obstruction is frequent in allergic bronchopulmonary aspergillosis, idiopathic chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis, and hypereosinophilic obliterative bronchiolitis. Corticosteroids are the cornerstone of therapy, but relapses are common. Therapies targeting interleukin 5/interleukin-5 are increasingly used in eosinophilic lung diseases.
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Affiliation(s)
- Vincent Cottin
- Service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Centre de référence coordonnateur des maladies pulmonaires rares (OrphaLung), 28 Avenue Doyen Lepine, Lyon Cedex 69677, France; Université Lyon 1, INRAE, UMR754, Lyon, France.
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Amratia DA, Viola H, Ioachimescu OC. Glucocorticoid therapy in respiratory illness: bench to bedside. J Investig Med 2022; 70:1662-1680. [DOI: 10.1136/jim-2021-002161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/07/2022]
Abstract
Each year, hundreds of millions of individuals are affected by respiratory disease leading to approximately 4 million deaths. Most respiratory pathologies involve substantially dysregulated immune processes that either fail to resolve the underlying process or actively exacerbate the disease. Therefore, clinicians have long considered immune-modulating corticosteroids (CSs), particularly glucocorticoids (GCs), as a critical tool for management of a wide spectrum of respiratory conditions. However, the complex interplay between effectiveness, risks and side effects can lead to different results, depending on the disease in consideration. In this comprehensive review, we present a summary of the bench and the bedside evidence regarding GC treatment in a spectrum of respiratory illnesses. We first describe here the experimental evidence of GC effects in the distal airways and/or parenchyma, both in vitro and in disease-specific animal studies, then we evaluate the recent clinical evidence regarding GC treatment in over 20 respiratory pathologies. Overall, CS remain a critical tool in the management of respiratory illness, but their benefits are dependent on the underlying pathology and should be weighed against patient-specific risks.
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Park S, Han D, Lee JE, Ryu DH, Kim HJ. Diagnostic index for acute eosinophilic pneumonia without bronchoscopy in military smokers. Korean J Intern Med 2022; 37:377-386. [PMID: 34905816 PMCID: PMC8925950 DOI: 10.3904/kjim.2021.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/05/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Acute eosinophilic pneumonia (AEP) is common among military smokers; however, bronchoscopy is required for the diagnosis. We aimed to derive and validate a scoring system to diagnose AEP without bronchoscopy. METHODS We conducted a retrospective study including patients diagnosed with AEP or any other pneumonia among military smokers hospitalized in the Armed Forces Capital Hospital from 15 November 2016 through 25 December 2019. The patients were divided into derivation and validation groups according to their admission day. Patient symptoms, laboratory findings, and computed tomography findings were candidate variables. Least absolute shrinkage and selection operator (LASSO) regression was used to calculate the scores for each variable. RESULTS Among 414 patients, AEP was confirmed in 54 of 279 patients (19.4%) in the derivation group and in 18 of 135 patients (13.3%) in the validation group. Ten variables were selected using LASSO regression: new-onset or a recently increased smoking (≤ 4 weeks) (8 points), interlobular septal thickening (5 points), absence of sputum (3 points), ground glass opacity (3 points), acute onset (≤ 3 days) (2 points), dyspnea (2 points), chest pain (2 points), leukocytosis (2 points), bronchovascular bundle thickening (2 points), and bilateral involvement (2 points). The area under the receiver-operating characteristic curve of the score to diagnose AEP was 0.997 (95% confidence interval, 0.992 to 1.000) in the derivation group and 0.985 (95% confidence interval, 0.965 to 1.000) in the validation group. CONCLUSION We introduce a scoring system that can distinguish AEP from other types of pneumonia in military smokers without the need for bronchoscopy.
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Affiliation(s)
- Sunmin Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Deokjae Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Ji Eun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Duck Hyun Ryu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
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Harne PS, Rao S, Malik M, Shepherd Z. Acute Eosinophilic Pneumonia Secondary to Menthol Cigarette Use: A Rare Phenomenon With a Review of Literature. J Investig Med High Impact Case Rep 2021; 8:2324709620925978. [PMID: 32462944 PMCID: PMC7262976 DOI: 10.1177/2324709620925978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
| | - Suman Rao
- SUNY Upstate Medical University, Syracuse, NY, USA
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Umekage Y, Okumura S, Tenma T, Kazebayashi Y, Hirai N, Minami Y, Doshita K, Sasaki T, Yamamoto Y, Ohsaki Y. Acute eosinophilic pneumonia following inhalation of turpentine oil: A case report. Respir Med Case Rep 2020; 31:101143. [PMID: 32676278 PMCID: PMC7352068 DOI: 10.1016/j.rmcr.2020.101143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/21/2020] [Accepted: 06/24/2020] [Indexed: 11/25/2022] Open
Abstract
Acute eosinophilic pneumonia (AEP) is an eosinophilic lung disease associated with environmental substances including smoking. Although the etiology of AEP has not been fully elucidated, it has been hypothesized that IL-33 plays a central role in the pathogenesis of AEP. Turpentine oil, from resins of pine trees, is not only used in paints, but also utilized in experimental animal models of inflammation because it leads to the production of inflammatory cytokines including IL-33. Here, we report the first case of AEP following turpentine oil inhalation. A 67-year-old woman reported using urushiol with turpentine oil to repair home goods. She had fever and persistent cough after turpentine inhalation over a very short period of time. The chest X-ray image showed consolidation in the upper right lung field. Laboratory findings indicated that there was no evidence of infection, collagen vascular diseases, and other allergic diseases that cause pneumonia, but analysis of the bronchoalveolar lavage fluid revealed 29% eosinophils with a small number of lipid-laden macrophages. With these findings, the diagnostic criteria of AEP was met. We rendered a diagnosis of AEP by inhalation of turpentine because no other cause for AEP was identified even with a structured questionnaire survey. The manifestations resolved immediately after steroid therapy. This is the first report of a case of AEP caused by the inhalation of turpentine oil.
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Affiliation(s)
- Yasuhiro Umekage
- Respiratory Center, Asahikawa Medical University Hospital, Japan
| | - Shunsuke Okumura
- Respiratory Center, Asahikawa Medical University Hospital, Japan
| | - Toshiyuki Tenma
- Respiratory Center, Asahikawa Medical University Hospital, Japan
| | | | - Noriko Hirai
- Respiratory Center, Asahikawa Medical University Hospital, Japan
| | - Yoshinori Minami
- Respiratory Center, Asahikawa Medical University Hospital, Japan
| | - Kazushi Doshita
- Respiratory Center, Asahikawa Medical University Hospital, Japan
| | - Takaaki Sasaki
- Respiratory Center, Asahikawa Medical University Hospital, Japan
| | - Yasushi Yamamoto
- Respiratory Center, Asahikawa Medical University Hospital, Japan
| | - Yoshinobu Ohsaki
- Respiratory Center, Asahikawa Medical University Hospital, Japan
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E-Cigarette or Vaping Product-Associated Lung Injury: A Review. Am J Med 2020; 133:657-663. [PMID: 32179055 DOI: 10.1016/j.amjmed.2020.02.004] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 12/20/2022]
Abstract
Since its introduction in the US market in 2007, the use of electronic nicotine delivery systems, colloquially referred to as e-cigarettes or "vaping" products, has increased substantially, particularly among high school children and young men. With the legalization of marijuana within multiple states in the United States and thus, coincident change in the public perception of its risk, the availability of multiple tetrahydrocannabinol (the psychoactive agent in marijuana)- and cannabidiol (a nonpsychogenic agent in marijuana)- containing vaping products has also increased tremendously. Since March 2019, there has been an ongoing epidemic of acute lung injury secondary to the use of e-cigarettes, with over 2600 cases and 60 deaths reported all over the United States; the term e-cigarette- or vaping product-associated lung injury is used. E-cigarette- or vaping product-associated lung injury is defined by the 1) presence of pulmonary infiltrates in imaging; 2) use of electronic nicotine delivery systems within the previous 90 days; and 3) absence of other possible causes such as infection, cardiac, neoplastic, or rheumatologic causes. A significant proportion of patients hospitalized with e-cigarette- or vaping product-associated lung injury have required admission in the intensive care unit, with mechanical ventilation needed in up to one-third of patients. Corticosteroids, supportive care, and further avoidance of vaping products remain the cornerstone of treatment. Although generally associated with an excellent prognosis, older patients and patients with underlying cardiac and pulmonary conditions are at risk for higher mortality and morbidity. This review article aims to describe e-cigarette- or vaping product-associated lung injury, its pathogenesis, clinical and radiological manifestations, and management.
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Choi JY, Lim JU, Jeong HJ, Lee JE, Rhee CK. Association between peripheral blood/bronchoalveolar lavage eosinophilia and significant oxygen requirements in patients with acute eosinophilic pneumonia. BMC Pulm Med 2020; 20:22. [PMID: 31992279 PMCID: PMC6986137 DOI: 10.1186/s12890-020-1056-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 01/17/2020] [Indexed: 11/15/2022] Open
Abstract
Background We investigated the association between a combination of two markers, peripheral (PEC) and bronchoalveolar lavage (BAL) eosinophil percentage (BEP), and oxygen requirements in patients with acute eosinophilic pneumonia (AEP). Methods We retrospectively reviewed the medical records of patients with AEP treated at the Armed Forces Capital Hospital between May 2012 and May 2017. We used correlation analyses to assess the association between PEC/BEP and clinical outcomes in AEP patients. Receiver operating characteristic (ROC) curve analyses were used to calculate the cut-off value for BEP that categorised patients requiring a significant oxygen supply. The BAL/blood eosinophil (BBE) score was introduced to stratify patients with peripheral eosinophilia and elevated BEP. Clinical characteristics and outcomes were compared between the different groups. Multiple logistic regression was performed for significant oxygen requirements using two different models using age, C-reactive protein (CRP), smoking duration, and BBE score (model 1) and age, CRP, BEP, and PEC (model 2). Results Among the 338 patients, 99.7% were male, and their mean age was 20.4 ± 1.4 years. Only 0.6% of patients were never smokers and the mean number of smoking days was 26.2 ± 25.4. Correlation analyses revealed that both the PaO2/FiO2 ratio and duration of oxygen supply were associated with BEP. ROC curve analyses indicated a cut-off level of 41.5%. Patients with a high BBE score had favourable outcomes in terms of hypoxemia, hospital days, intensive care unit admission, oxygen supply days, and steroid treatment days. Multiple logistic regression revealed that BEP and BBE score tended to be associated with significant oxygen requirements. Conclusions In this study, we revealed that both peripheral and BAL eosinophilia is associated with favourable outcomes in AEP patients.
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Affiliation(s)
- Joon Young Choi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Jeong Uk Lim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Jung Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Armed Forces Capital Hospital, Seongnam, Republic of Korea, 222, Banpo-daero Seocho-gu, Seoul, 06591, Republic of Korea
| | - Ji Eun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Armed Forces Capital Hospital, Seongnam, Republic of Korea, 222, Banpo-daero Seocho-gu, Seoul, 06591, Republic of Korea
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Dougherty SC, Ghaus S, Debesa O. Extracorporeal Membrane Oxygenation in Severe Acute Eosinophilic Pneumonia. Front Med (Lausanne) 2019; 6:65. [PMID: 31024915 PMCID: PMC6467954 DOI: 10.3389/fmed.2019.00065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/15/2019] [Indexed: 01/09/2023] Open
Abstract
Acute Eosinophilic Pneumonia (AEP) is a potentially fatal cause of hypoxemic respiratory failure characterized by fever, diffuse bilateral pulmonary infiltrates, and pulmonary eosinophilia. Shown to be associated with a number of environmental exposures and lifestyle choices, AEP has a good prognosis when diagnosed early and treated with corticosteroids. In this clinical case report, we detail the presentation, evaluation, diagnosis, and management of a 40-year old male who presented to the emergency department with dyspnea, chills, and diaphoresis. He had a history of pulmonary embolism 8 years prior but was otherwise healthy, though he had re-started smoking cigarettes a week prior to presentation. Initial chest CT scan revealed widespread mixed groundglass and solid airspace opacities; over the next 12 hours, he rapidly decompensated and after not responding to other invasive mechanical ventilation, was emergently cannulated for veno-venous extracorporeal membrane oxygenation (V-V ECMO). Bronchoalveolar lavage later revealed pulmonary eosinophilia, and after an infectious workup was negative, a diagnosis of AEP was reached and the patient was started on corticosteroids. To our knowledge, this is one of few published cases of AEP requiring V-V ECMO for clinical stabilization, highlighting the utility of this treatment modality in severe disease.
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Affiliation(s)
- Sean C Dougherty
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Sophia Ghaus
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Orlando Debesa
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
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Ota K, Sasabuchi Y, Matsui H, Jo T, Fushimi K, Yasunaga H. Age distribution and seasonality in acute eosinophilic pneumonia: analysis using a national inpatient database. BMC Pulm Med 2019; 19:38. [PMID: 30755187 PMCID: PMC6371551 DOI: 10.1186/s12890-019-0800-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 02/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute eosinophilic pneumonia (AEP) is a rare inflammatory lung disease. Previous studies have shown that most patients with AEP are aged 20 to 40 years, whereas several case studies have included older patients with AEP. These studies also suggested that AEP is more prevalent in summer, but they were limited due to their small sample sizes. We therefore investigated the age distribution and seasonality among patients with AEP using a national inpatient database. METHODS Using the Japanese Diagnosis Procedure Combination database, we identified patients with a recorded diagnosis of AEP from 1 July 2010 to 31 March 2015. We examined patient characteristics and clinical practices including age, sex, seasonal variation, length of stay, use of corticosteroids, use of mechanical ventilation, and in-hospital mortality. RESULTS During the 57-month study period, we identified 213 inpatients with AEP. The age distribution of AEP peaked twice: at 15 to 24 years and 65 to 79 years. The proportion of patients with AEP was highest in summer for those aged < 40 years, whereas it was distributed evenly throughout the year for those aged ≥ 40 years. The interval from hospital admission to corticosteroid administration and the duration of corticosteroid use were significantly longer in the older than younger age group. CONCLUSIONS The age distribution of patients with AEP was bimodal, and seasonality was undetected in older patients. Older patients may be more likely to have delayed and prolonged treatment.
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Affiliation(s)
- Koshi Ota
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan. .,Department of Emergency, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan.
| | - Yusuke Sasabuchi
- Data Science Center, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi-ken, 329-0498, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113 - 8510, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan
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Takei R, Arita M, Kumagai S, Ito Y, Takaiwa T, Tokioka F, Itakura J, Ishida T. Traction bronchiectasis on high-resolution computed tomography may predict fatal acute eosinophilic pneumonia. Respir Investig 2018; 57:67-72. [PMID: 30528687 DOI: 10.1016/j.resinv.2018.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 09/12/2018] [Accepted: 09/18/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Most patients with acute eosinophilic pneumonia (AEP) show rapid improvement. However, some cases of AEP prove fatal. The aims of this study were to determine the clinical, radiographic, and pathologic characteristics of patients in whom AEP has a fatal outcome and to identify predictors of a poor prognosis. METHODS We retrospectively identified the medical records of all patients diagnosed with AEP at our institution in Japan from July 2005 to July 2013. RESULTS There were four deaths among 41 patients diagnosed to have AEP during the study period. All the patients who died were male; three cases were idiopathic and one was medication-related. The median bronchoalveolar lavage eosinophil differential count was 59%. An autopsy was performed on the patient with medication-related AEP who died and the pathologic finding was diffuse alveolar damage with eosinophilic infiltration. Diffuse ground-glass attenuation and traction bronchiectasis (TBE) were identified on high-resolution computed tomography in the four patients with fatal AEP. TBE was observed in six patients (five with idiopathic AEP, one with medication-related AEP), and 67% of these patients died. None of the patients with smoking-related AEP had TBE; all these patients had better responses to treatment and survived. CONCLUSIONS We observed the characteristics of patients with fatal AEP who did not respond to treatment. TBE was observed in all fatal cases and may be associated with a poor prognosis.
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Affiliation(s)
- Reoto Takei
- Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan.
| | - Machiko Arita
- Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
| | - Shogo Kumagai
- Division of Cancer Immunology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Japan
| | - Yuhei Ito
- Department of Respiratory Medicine, Ise Red Cross Hospital, Ise, Japan
| | - Takuya Takaiwa
- Department of Respiratory Medicine, Sakai City Medical Center, Sakai, Japan
| | - Fumiaki Tokioka
- Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
| | - Junya Itakura
- Department of Anatomic Pathology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Tadashi Ishida
- Department of Respiratory Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
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Sine CR, Hiles PD, Scoville SL, Haynes RL, Allan PF, Franks TJ, Morris MJ, Osborn EC. Acute eosinophilic pneumonia in the deployed military setting. Respir Med 2018; 137:123-128. [PMID: 29605194 DOI: 10.1016/j.rmed.2018.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/24/2018] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
Abstract
RATIONALE Acute eosinophilic pneumonia (AEP) is a rare but important cause of severe respiratory failure most typically caused by cigarette smoking, but can also be caused by medications, illicit drugs, infections and environmental exposures. There is growing evidence that disease severity varies and not all patients require mechanical ventilation or even supplemental oxygen. OBJECTIVES To compare patients with AEP treated at Landstuhl Regional Medical Center (LRMC) to those in other published series, and to provide recommendations regarding diagnosis and treatment of AEP. METHODS A retrospective chart review was completed on forty-three cases of AEP which were identified from March 2003 through March 2010 at LRMC, Germany. RESULTS Tobacco smoking was reported by 91% of our patients. Only 33% of patients in our series had a fever (temperature > 100.4 °F) at presentation. Peripheral eosinophilia (>5%) was present in 35% on initial CBC, but was seen in 72% of patients during their hospital course. Hypoxemia, as measured by PaO2/FiO2 ratio, seemed to be less severe in patients with higher levels of bronchoalveolar (BAL) eosinophilia percentage. CONCLUSIONS Based on our experience and literature review, we recommend adjustments to the diagnostic criteria which may increase consideration of this etiology for acute respiratory illnesses as well as provide clinical clues we have found particularly helpful. Similar to recent reports of initial peripheral eosinophilia correlating with less severe presentation we found that higher BAL eosinophilia correlated with less severe hypoxemia.
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Affiliation(s)
- Christy R Sine
- Pulmonary/Critical Care Service, Landstuhl Regional Medical Center, Landstuhl, Germany; Pulmonary/Critical Care Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, United States.
| | - Paul D Hiles
- Pulmonary/Critical Care Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, United States
| | | | - Ralph L Haynes
- Pulmonary/Critical Care Service, Landstuhl Regional Medical Center, Landstuhl, Germany
| | - Patrick F Allan
- Pulmonary/Critical Care Service, Landstuhl Regional Medical Center, Landstuhl, Germany
| | - Teri J Franks
- Pulmonary & Mediastinal Pathology, The Joint Pathology Center, Silver Spring, MD, United States
| | - Michael J Morris
- Pulmonary/Critical Care Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, United States
| | - Erik C Osborn
- Pulmonary Critical Care Sleep Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA, United States
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Bartal C, Sagy I, Barski L. Drug-induced eosinophilic pneumonia: A review of 196 case reports. Medicine (Baltimore) 2018; 97:e9688. [PMID: 29369189 PMCID: PMC5794373 DOI: 10.1097/md.0000000000009688] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 12/30/2017] [Accepted: 01/02/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Eosinophilic pneumonia (EP) is an important subset of patients who present with pulmonary infiltrates and eosinophilia (PIE). EP is classified by chronicity and etiology and drug-induced EP is the main cause of secondary EP. The primary goal of this review was to examine all the case reports published since the syndrome was defined in 1990. It remains unclear whether acute or chronic EP (AEP or CEP) represent different diseases, and the secondary goal of this review is to determine if there are factors that may help distinguish these 2 entities. METHODS PubMed (MEDLINE and Medical Subject Headings) was searched for case reports of drug-induced EP or PIE syndrome published between 1990 and 2017. Case reports were only included if the diagnostic criteria for AEP or CEP were fulfilled. For each case, data were extracted pertaining to age, sex, type of medication associated with the disease, time from the onset of symptoms to diagnosis, eosinophil counts in the blood, eosinophil fractions in bronchoalveolar lavage (BAL) fluid, initial chest radiograph and computed tomography results, use of mechanical ventilation, and use of steroid treatment and recurrence. RESULTS We found 196 case reports describing drug-induced EP. The leading cause was daptomycin. From our review, we found that AEP is more common in younger patients with no gender preference. Eosinophilia in the blood at the time of diagnosis characterized only the CEP patients (80% in CEP vs. 20% in AEP). Abnormal findings on radiographic imagine was similar in both syndromes. A significant portion of AEP patients (20%) presented with acute respiratory failure requiring mechanical ventilation. Most patients with EP were treated with steroids with a higher rate of relapse observed in patients with CEP. CONCLUSION AEP is a much more fulminant and severe disease than the gradual onset and slowly progressive nature of CEP. The pathogenesis of AEP and CEP remains unclear. However, there is significant clinical overlap among AEP and CEP that are associated with drug toxicity, suggesting the possibility that AEP and CEP are distinct clinical presentations that share a common pathogenic pathway.
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Current Concepts in Pathogenesis, Diagnosis, and Management of Smoking-Related Interstitial Lung Diseases. Chest 2017; 154:394-408. [PMID: 29222007 DOI: 10.1016/j.chest.2017.11.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/01/2017] [Accepted: 11/26/2017] [Indexed: 11/21/2022] Open
Abstract
Tobacco exposure results in various changes to the airways and lung parenchyma. Although emphysema represents the more common injury pattern, in some individuals, cigarette smoke injures alveolar epithelial cells and other lung cells, resulting in diffuse infiltrates and parenchymal fibrosis. Smoking can trigger interstitial injury patterns mediated via recruitment and inappropriate persistence of myeloid and other immune cells, including eosinophils. As our understanding of the role of cigarette smoke constituents in triggering lung injury continues to evolve, so does our recognition of the spectrum of smoking-related interstitial lung changes. Although respiratory bronchiolitis-interstitial lung disease, desquamative interstitial pneumonia, pulmonary Langerhans cell histiocytosis, and acute eosinophilic pneumonia have a well-established association with tobacco use, its role and impact on idiopathic pulmonary fibrosis, combined pulmonary fibrosis and emphysema, and connective tissue disease-related interstitial lung diseases is still ambiguous. Smoking-related interstitial fibrosis is a relatively newly appreciated entity with distinct histopathologic features but with unclear clinical ramifications. Increased implementation of lung cancer screening programs and utilization of CT scans in thoracic imaging have also resulted in increased identification of "incidental" or "subclinical" interstitial lung changes in smokers, the ensuing impact of which remains to be studied.
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Oishi K, Hirano T, Suetake R, Ohata S, Yamaji Y, Ito K, Edakuni N, Matsunaga K. Exhaled nitric oxide measurements in patients with acute-onset interstitial lung disease. J Breath Res 2017; 11:036001. [DOI: 10.1088/1752-7163/aa6c4b] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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De Giacomi F, Decker PA, Vassallo R, Ryu JH. Acute Eosinophilic Pneumonia: Correlation of Clinical Characteristics With Underlying Cause. Chest 2017; 152:379-385. [PMID: 28286263 DOI: 10.1016/j.chest.2017.03.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 02/13/2017] [Accepted: 03/01/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Acute eosinophilic pneumonia (AEP) is an uncommon disease, often indistinguishable from ARDS or community-acquired pneumonia at initial presentation. AEP can be idiopathic, but identifiable causes include medications and inhalational exposures, including cigarette smoke. METHODS Using a computer-assisted search, we retrospectively identified and reviewed the medical records of all patients diagnosed with AEP between January 1, 1998, and June 30, 2016, at our institution. Demographic and clinical data were extracted, including exposures (occupational, environmental, recreational, pharmacologic, and smoking), laboratory and radiologic findings, treatments, hospitalization (including ICU stay), and subsequent clinical course. RESULTS Among 36 consecutive patients with AEP, 11 were smoking-related cases, six were medication-related cases and 19 were idiopathic. Smoking-related AEP included six first-time smokers and five ex-smokers who had resumed smoking after a period of abstinence. Patients with smoking-related AEP were younger compared with both medication-related and idiopathic AEP cases (median age: 22 vs 47.5 vs 55 years, respectively; P = .004). Patients with smoking-related AEP were less likely to be associated with peripheral eosinophilia at presentation (36% vs 50% vs 58%; P = .52) but more likely to be hospitalized (100% vs 50% vs 63%; P = .039), including a longer ICU stay, compared with medication-related and idiopathic cases. CONCLUSIONS AEP is associated with a good prognosis when recognized and treated promptly. Compared with medication-related and idiopathic AEP, smoking-related AEP was less likely to be associated with peripheral eosinophilia at presentation but was characterized by more severe disease manifestations.
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Affiliation(s)
- Federica De Giacomi
- Dipartimento Cardio-Toraco-Vascolare, University of Milan-Bicocca, Respiratory Unit, San Gerardo Hospital, Monza, Italy; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Paul A Decker
- Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Robert Vassallo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Kligerman S, Franks TJ, Galvin JR. Clinical-Radiologic-Pathologic Correlation of Smoking-Related Diffuse Parenchymal Lung Disease. Radiol Clin North Am 2016; 54:1047-1063. [PMID: 27719975 DOI: 10.1016/j.rcl.2016.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The direct toxicity of cigarette smoke and the body's subsequent response to this lung injury leads to a wide array of pathologic manifestations and disease states that lead to both reversible and irreversible injury to the large airways, small airways, alveolar walls, and alveolar spaces. These include emphysema, bronchitis, bronchiolitis, acute eosinophilic pneumonia, pulmonary Langerhans cell histiocytosis, respiratory bronchiolitis, desquamative interstitial pneumonia, and pulmonary fibrosis. Although these various forms of injury have different pathologic and imaging manifestations, they are all part of the spectrum of smoking-related diffuse parenchymal lung disease.
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Affiliation(s)
- Seth Kligerman
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21231, USA.
| | - Teri J Franks
- Department of Defense, Defense Health Agency, Joint Pathology Center, 606 Stephen Sitter Avenue, Silver Spring, MD 20910-1290, USA
| | - Jeffrey R Galvin
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21231, USA; Department of Thoracic Radiology, American Institute for Radiologic Pathology, 1010 Wayne Avenue, Suite 320, Silver Spring, MD 20910, USA
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Abstract
Eosinophilic lung diseases especially comprise eosinophilic pneumonia or as the more transient Löffler syndrome, which is most often due to parasitic infections. The diagnosis of eosinophilic pneumonia is based on characteristic clinical-imaging features and the demonstration of alveolar eosinophilia, defined as at least 25% eosinophils at BAL. Peripheral blood eosinophilia is common but may be absent at presentation in idiopathic acute eosinophilic pneumonia, which may be misdiagnosed as severe infectious pneumonia. All possible causes of eosinophilia, including drug, toxin, fungus related etiologies, must be thoroughly investigated. Extrathoracic manifestations should raise the suspicion of eosinophilic granulomatosis with polyangiitis.
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Jo HE, Corte TJ, Wort SJ, Eves ND, Piper A, Wainwright C. Year in review 2015: Interstitial lung disease, pulmonary vascular disease, pulmonary function, sleep and ventilation, cystic fibrosis and paediatric lung disease. Respirology 2016; 21:556-66. [DOI: 10.1111/resp.12749] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 01/20/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Helen E. Jo
- Department of Respiratory and Sleep Medicine; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- University of Sydney; Sydney New South Wales Australia
| | - Tamera J. Corte
- Department of Respiratory and Sleep Medicine; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- University of Sydney; Sydney New South Wales Australia
| | - Stephen J. Wort
- Department of Pulmonary Hypertension; Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London; London UK
| | - Neil D. Eves
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development; University of British Columbia; Kelowna British Columbia Canada
| | - Amanda Piper
- Department of Respiratory and Sleep Medicine; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- Woolcock Institute of Medical Research; University of Sydney; Sydney New South Wales Australia
| | - Claire Wainwright
- Lady Cilento Children's Hospital, School of Medicine; University of Queensland; Brisbane Queensland Australia
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Heffner JE. Chipping away at duration of therapy for idiopathic acute eosinophilic pneumonia. Respirology 2015; 20:1151-2. [PMID: 26365360 DOI: 10.1111/resp.12643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- John E Heffner
- Department of Medicine, Providence Portland Medical Center, Oregon Health and Science Center, Portland, Oregon, USA
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