Eosinophilic pneumonias

A case of naltrexone-induced acute eosinophilic pneumonia

Acute eosinophilic pneumonia (AEP) is a rare cause of acute respiratory failure. Clinical presentations can range from dyspnoea, fever and cough, to rapidly progressive and potentially fulminant respiratory failure. While its exact cause is often unknown, associations with inhalational injuries and exposures to new medications have been described.We report a case of a middle-aged, non-smoking man with a history of alcohol use disorder. He presented with 4 days of shortness of breath that started hours after taking injectable naltrexone (Vivitrol). The patient had rapidly worsening hypoxaemia, necessitating emergent bronchoscopy with transbronchial biopsies and bronchoalveolar lavage which showed 66% eosinophils. The patient was intubated for the procedure and unable to get extubated due to worsening hypoxaemic respiratory failure with high fractional inspired oxygen requirements. Chest radiograph showed worsening lung infiltrates and with a high index of suspicion for AEP, he was started empirically on methylprednisolone. He had rapid improvement in his respiratory status and was extubated on day 5 of admission then discharged on day 8. Histopathological examination confirmed acute/subacute eosinophilic pneumonia. A 3-week post-discharge follow-up chest radiograph confirmed the full resolution of pulmonary infiltrates.Naltrexone-induced AEP is rare, with only six other cases reported in the literature. Careful history taking and prompt evaluation for AEP are important given the potential for rapid progression to acute hypoxic respiratory failure and the excellent response to steroid treatment.

A Rare Case of an Eosinophilic Pleural Effusion and Loculated Ascites Associated with Strongyloides stercoralis Hyperinfection Syndrome in California

Introduction. Strongyloides stercoralis causes a helminthic infection that occurs via penetration of the skin with migration to the bloodstream, tracheobronchial tree, and gastrointestinal system. Pulmonary manifestations are rare and are typically seen in immunosuppressed patients who have Strongyloides stercoralis hyperinfection syndrome. Eosinophilic pleural effusions are rare in strongyloidiasis and only cited in a few case reports. Case Presentation. A 45-year-old male with a past medical history of diabetes mellitus, alcoholic cirrhosis, and end-stage renal disease presented to the emergency department with abdominal pain and dyspnea. Imaging studies demonstrated large bilateral pleural effusions, and he subsequently underwent an ultrasound-guided thoracentesis on the right hemithorax, yielding an exudative eosinophilic pleural effusion. An extensive hematology, gastroenterology, and infectious work-up was pursued. Strongyloides immunoglobulin G was positive, and he was successfully treated with ivermectin. Discussion. Eosinophilic pleural effusions related to strongyloidiasis are exceedingly rare. Clinicians should consider Strongyloides stercoralis infection as a part of the differential diagnosis when evaluating immunosuppressed patients with eosinophilic pleural effusions. Loculated abdominal fluid may also be a rare manifestation of Strongyloides stercoralis hyperinfection syndrome.

Diagnostic journey of chronic eosinophilic pneumonia masked as lung cancer: a rare case report

Introduction and Importance

Chronic eosinophilic pneumonia (CEP) is an idiopathic condition characterized by unusually high eosinophil infiltration in the lungs' interstitium and alveolar spaces. It is extremely rare, accounting for fewer than 3% of all interstitial lung diseases. CEP is frequently misdiagnosed as lung cancer, which can have catastrophic consequences for sufferers. When assessing patients with lung disease, doctors should be aware of CEP's symptoms and take its prognosis into account because it is a curable disorder.

Case Presentation

A 40-year-old female presented in the outpatient department of gynecology with a history of abnormal vaginal bleeding for 3 months and mild shortness of breath without any other significant medical history or being under any medications. Physical examination findings were not significant.

Clinical Discussion

Ultrasound revealed adenomyosis and a hysterectomy was planned. Chest radiograph revealed lung mass and computed tomography scan showed a well-defined mass with a pleural-based nodule. Histopathology revealed interstitial fibrosis and eosinophilic microabscesses. CEP was diagnosed and oral prednisolone was started with a 0.5 mg/kg/day dose. Chest radiographic abnormalities resolved after one month of treatment. Currently, she is asymptomatic.

Conclusion

Early recognition and diagnosis of lung masses are essential for prompt treatment with corticosteroids. CEP can mimic lung malignancy and should be considered in patients with related symptoms.

Chronic Eosinophilic Pneumonia: Unraveling Recurrent Chest Infections in a Female Patient With a Family History of Atopy

Eosinophilic pneumonia is a rare condition characterized by the infiltration of eosinophils in the lungs. We present a case of eosinophilic pneumonia in a 51-year-old British Caucasian female with a history of lichen sclerosus, deranged liver function tests, and a family history of atopy. The patient presented with fever, shortness of breath, lethargy, dry cough, and weight loss over a three-month period. Initial treatment with antibiotics did not yield improvement, and further investigations revealed marked eosinophilia on blood count. Bronchoscopy and biopsies confirmed the diagnosis of eosinophilic pneumonia, and the patient responded well to a tapering dose of prednisolone. This study highlights the importance of considering eosinophilic pneumonia in patients with unexplained respiratory symptoms and eosinophilia and emphasizes the role of bronchoscopy in establishing a definitive diagnosis.

A Case of Tropical Pulmonary Eosinophilia With Incomplete Response to Diethylcarbamazine Therapy

Tropical pulmonary eosinophilia (TPE) is a specific pulmonary manifestation of lymphatic filariasis. There is overwhelming infiltration of eosinophils in the lung parenchyma in response to microfilaria. The characteristic features include paroxysmal respiratory symptoms, strikingly high blood eosinophil count, elevated level of immunoglobulin (Ig) E along with high titer of anti-filarial antibody. Treatment with diethylcarbamazine (DEC) has an excellent favorable response. However, recovery may often be incomplete. We present a case of a 36-year-old man with TPE who had complete symptomatic improvement after a three-week course of DEC, but only a partial response in radiological and pulmonary function abnormalities.

A comprehensive summary of disease variants implicated in metal allergy

Allergic disease represents one of the most prominent global public health crises of the 21^st century. Although many different substances are known to produce hypersensitivity responses, metals constitute one of the major classes of allergens responsible for a disproportionately large segment of the total burden of disease associated with allergy. Some of the most prevalent forms of metal allergy - including allergic contact dermatitis - are well-recognized; however, to our knowledge, a comprehensive review of the many unique disease variants implicated in human cases of metal allergy is not available within the current scientific literature. Consequently, the main goal in composing this review was to (1) generate an up-to-date reference document containing this information to assist in the efforts of lab researchers, clinicians, regulatory toxicologists, industrial hygienists, and other scientists concerned with metal allergy and (2) identify knowledge gaps related to disease. Accordingly, an extensive review of the scientific literature was performed - from which, hundreds of publications describing cases of metal-specific allergic responses in human patients were identified, collected, and analyzed. The information obtained from these articles was then used to compile an exhaustive list of distinctive dermal/ocular, respiratory, gastrointestinal, and systemic hypersensitivity responses associated with metal allergy. Each of these disease variants is discussed briefly within this review, wherein specific metals implicated in each response type are identified, underlying immunological mechanisms are summarized, and major clinical presentations of each reaction are described.Abbreviations: ACD: allergic contact dermatitis, AHR: airway hyperreactivity, ASIA: autoimmune/ autoinflammatory syndrome induced by adjuvants, BAL: bronchoalveolar lavage, CBD: chronic beryllium disease, CTCL: cutaneous T-cell lymphoma, CTL: cytotoxic T-Lymphocyte, DRESS: drug reaction with eosinophilia and systemic symptoms, GERD: gastro-esophageal reflux disease, GI: gastrointestinal, GIP: giant cell interstitial pneumonia, GM-CSF: granulocyte macrophage-colony stimulating factor, HMLD: hard metal lung disease, HMW: high molecular weight, IBS: irritable bowel syndrome, Ig: immunoglobulin, IL: interleukin, LMW: low molecular weight, PAP: pulmonary alveolar proteinosis, PPE: personal protective equipment, PRR: pathogen recognition receptor, SLE: systemic lupus erythematosus, SNAS: systemic nickel allergy syndrome, Th: helper T-cell, UC: ulcerative colitis, UV: ultraviolet.

Stat3/IL-6 signaling mediates sustained pneumonia induced by Agiostrongylus cantonensis

Angiostrongylus cantonensis (AC) is well-documented that parasitizes the host brain and causes eosinophilic meningitis. The migration route of AC in permissive hosts is well demonstrated, while in nonpermissive hosts, it remains to be fully defined. In the present study, we exploited live imaging technology, morphological and pathological configuration analysis, and molecular biological technologies to explore the migration route of AC and the accompanying tissue damage in nonpermissive and permissive hosts. Our data indicated that, in nonpermissive host mouse, AC larvae migrated from intestinal wall to liver at 2 hours post-infection (hpi), from liver to lung at 4 hpi and then from lung to brain at 8 hpi. AC larval migration caused fatal lung injury (pneumonia) during acute and early infection phases, along with significant activation of Stat3/IL-6 signaling. In addition, AC induce sustained interstitial pneumonia in mouse and rat and pulmonary fibrosis only in rat during late infection phase. Moreover, during the early and late infection phases, Th2 cytokine expression and Stat3 and IL-6 signaling were persistently enhanced and myeloid macrophage cells were notably enriched in host lung, and administration of Stat3 and IL-6 inhibitors (C188-9 and LMT-28) attenuated AC infection-induced acute pneumonia in mice. Overall, we are the first to provide direct and systemic laboratory evidence of AC migration route in a nonpermissive host and report that infection with a high dose of AC larvae could result in acute and fatal pneumonia through Stat3/IL-6 signaling in mice. These findings may present a feasible to rational strategy to minimize the pathogenesis induced by AC.

Angiostrongylus cantonensis is a well-known nematode parasitizing the host brain and is the leading cause of eosinophilic meningitis worldwide. Our study reports the migration route of Angiostrongylus cantonensis larvae in non-permissive host mouse and discovers that the larvae could induce fatal pneumonia in mouse lung during acute and early infection phase characterized by activation of Stat3/IL-6 signaling. Moreover, administration of inhibitors targeting Stat3/IL-6 signaling could significantly attenuate the AC-induced pneumonia of non-permissive host mouse, providing an effective candidate target for intervention of this severe parasitic pneumonia. These findings expand our understanding of Angiostrongyliasis cantonensis and indicate that more attention to AC-induced pneumonia is required when treatment for Angiostrongyliasis cantonensis in the future.

Loeffler's syndrome mimicking lung tumor and pneumonia in a child: A case report

Loeffler's syndrome is a rare and benign eosinophilic pneumonia which is commonly transient and self-limiting. Herein we report a 12-year-old boy who presented with dry cough, hemoptysis, chest pain, no fever and diminished breath sounds on the right lung. Chest imaging showed a consolidation lesion with bronchograms in the right upper and middle lobes, accompanied by a right free-flowing pleural effusion. Laboratory studies showed elevated C-reactive protein levels, and an eosinophil count of 13.7%. A lung biopsy was performed to diagnose the Loeffler's syndrome. The patient's condition was improving significantly with antibiotic therapy and is now followed up closely.

Eosinophilic airway diseases: basic science, clinical manifestations and future challenges

Eosinophils have a broad range of functions, both homeostatic and pathological, mediated through an array of cell surface receptors and specific secretory granules that promote interactions with their microenvironment. Eosinophil development, differentiation, activation, survival and recruitment are closely regulated by a number of type 2 cytokines, including interleukin (IL)-5, the key driver of eosinophilopoiesis. Evidence shows that type 2 inflammation, driven mainly by interleukin (IL)-4, IL-5 and IL-13, plays an important role in the pathophysiology of eosinophilic airway diseases, including asthma, chronic rhinosinusitis with nasal polyps, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome. Several biologic therapies have been developed to suppress type 2 inflammation, namely mepolizumab, reslizumab, benralizumab, dupilumab, omalizumab and tezepelumab. While these therapies have been associated with clinical benefits in a range of eosinophilic diseases, their development has highlighted several challenges and directions for future research. These include the need for further information on disease progression and identification of treatable traits, including clinical characteristics or biomarkers that will improve the prediction of treatment response. The Nordic countries have a long tradition of collaboration using patient registries and Nordic asthma registries provide unique opportunities to address these research questions. One example of such a registry is the NORdic Dataset for aSThmA Research (NORDSTAR), a longitudinal population-based dataset containing all 3.3 million individuals with asthma from four Nordic countries (Denmark, Finland, Norway and Sweden). Large-scale, real-world registry data such as those from Nordic countries may provide important information regarding the progression of eosinophilic asthma, in addition to clinical characteristics or biomarkers that could allow targeted treatment and ensure optimal patient outcomes.

Important Nematodes in Children

Intestinal nematode infections caused by soil-transmitted helminths (STH), such as the roundworm Ascaris lumbricoides, the whipworm Trichuris trichiura, and the hookworms Ancylostoma duodenale, and Necator americanus, infect more than 1 billion people throughout the world. School-aged children tend to harbor the greatest numbers of intestinal worms, and as a result, experience more adverse health consequences, such as poor growth, anemia, and cognitive decline. Clinicians should maintain a high degree of suspicion in endemic areas when patients present with surgical abdomens, particularly children. Current antihelminthic drugs are moderately effective, but reinfection is possible. Global efforts are needed to eradicate STH infections.

Gut Microbiota Modulation as a Potential Target for the Treatment of Lung Infections

The gastrointestinal and respiratory systems are colonized by a complex ecosystem of microorganisms called the microbiota. These microorganisms co-evolved over millions of years with the host, creating a symbiotic relationship that is fundamental for promoting host homeostasis by producing bioactive metabolites and antimicrobial molecules, and regulating the immune and inflammatory responses. Imbalance in the abundance, diversity, and function of the gut microbiota (known as dysbiosis) have been shown to increase host susceptibility to infections in the lungs, suggesting crosstalk between these organs. This crosstalk is now referred to as the gut-lung axis. Hence, the use of probiotics, prebiotics, and synbiotics for modulation of gut microbiota has been studied based on their effectiveness in reducing the duration and severity of respiratory tract infections, mainly owing to their effects on preventing pathogen colonization and modulating the immune system. This review discusses the role and responses of probiotics, prebiotics, and synbiotics in the gut-lung axis in the face of lung infections.

Eosinophil-mediated inflammation in the absence of eosinophilia

The increase of eosinophil levels is a hallmark of type-2 inflammation. Blood eosinophil counts act as a convenient biomarker for asthma phenotyping and the selection of biologics, and they are even used as a prognostic factor for severe coronavirus disease 2019. However, the circulating eosinophil count does not always reflect tissue eosinophilia and vice versa. The mismatch of blood and tissue eosinophilia can be seen in various clinical settings. For example, blood eosinophil levels in patients with acute eosinophilic pneumonia are often within normal range despite the marked symptoms and increased number of eosinophils in bronchoalveolar lavage fluid. Histological studies using immunostaining for eosinophil granule proteins have revealed the extracellular deposition of granule proteins coincident with pathological conditions, even in the absence of a significant eosinophil infiltrate. The marked deposition of eosinophil granule proteins in tissue is often associated with cytolytic degranulation. Recent studies have indicated that extracellular trap cell death (ETosis) is a major mechanism of cytolysis. Cytolytic ETosis is a total cell degranulation in which cytoplasmic and nuclear contents, including DNA and histones that act as alarmins, are also released. In the present review, eosinophil-mediated inflammation in such mismatch conditions is discussed.

Emerging Evidence for Pleiotropism of Eosinophils

Eosinophils are complex granulocytes with the capacity to react upon diverse stimuli due to their numerous and variable surface receptors, which allows them to respond in very different manners. Traditionally believed to be only part of parasitic and allergic/asthmatic immune responses, as scientific studies arise, the paradigm about these cells is continuously changing, adding layers of complexity to their roles in homeostasis and disease. Developing principally in the bone marrow by the action of IL-5 and granulocyte macrophage colony-stimulating factor GM-CSF, eosinophils migrate from the blood to very different organs, performing multiple functions in tissue homeostasis as in the gastrointestinal tract, thymus, uterus, mammary glands, liver, and skeletal muscle. In organs such as the lungs and gastrointestinal tract, eosinophils are able to act as immune regulatory cells and also to perform direct actions against parasites, and bacteria, where novel mechanisms of immune defense as extracellular DNA traps are key factors. Besides, eosinophils, are of importance in an effective response against viral pathogens by their nuclease enzymatic activity and have been lately described as involved in severe acute respiratory syndrome coronavirus SARS-CoV-2 immunity. The pleiotropic role of eosinophils is sustained because eosinophils can be also detrimental to human physiology, for example, in diseases like allergies, asthma, and eosinophilic esophagitis, where exosomes can be significant pathophysiologic units. These eosinophilic pathologies, require specific treatments by eosinophils control, such as new monoclonal antibodies like mepolizumab, reslizumab, and benralizumab. In this review, we describe the roles of eosinophils as effectors and regulatory cells and their involvement in pathological disorders and treatment.

Daptomycin-induced eosinophilic pneumonia: Are there any risk factors?

OBJECTIVES

Daptomycin is a widely used antibiotic. Rhabdomyolysis related to daptomycin is one of the adverse effects of treatment, justifying the need for regular monitoring of muscle enzymes throughout treatment. Daptomycin may also lead to eosinophilic pneumonia. However, risk factors for this adverse reaction have not been identified and do not permit targeting of at-risk populations who could benefit from appropriate monitoring.

PATIENTS AND METHODS

Literature was reviewed for cases of daptomycin-induced eosinophilic pneumonia (DIEP), which that were compared to cases of patients without this adverse effect.

RESULTS

Fifty patients with DIEP and 54 controls were identified. Age, sex, and treatment dose are not associated with the occurrence of DIEP. A high dose of daptomycin is not associated with an early onset of DIEP. About one third of patients with eosinophilic lung disease have diabetes or renal impairment.

CONCLUSIONS

Further studies may help to identify additional factors.

Il4ra-independent vaginal eosinophil accumulation following helminth infection exacerbates epithelial ulcerative pathology of HSV-2 infection

How helminths influence the pathogenesis of sexually transmitted viral infections is not comprehensively understood. Here, we show that an acute helminth infection (Nippostrongylus brasiliensis [Nb]) induced a type 2 immune profile in the female genital tract (FGT). This leads to heightened epithelial ulceration and pathology in subsequent herpes simplex virus (HSV)-2 infection. This was IL-5-dependent but IL-4 receptor alpha (Il4ra) independent, associated with increased FGT eosinophils, raised vaginal IL-33, and enhanced epithelial necrosis. Vaginal eosinophil accumulation was promoted by IL-33 induction following targeted vaginal epithelium damage from a papain challenge. Inhibition of IL-33 protected against Nb-exacerbated HSV-2 pathology. Eosinophil depletion reduced IL-33 release and HSV-2 ulceration in Nb-infected mice. These findings demonstrate that Nb-initiated FGT eosinophil recruitment promotes an eosinophil, IL-33, and IL-5 inflammatory circuit that enhances vaginal epithelial necrosis and pathology following HSV-2 infection. These findings identify a mechanistic framework as to how helminth infections can exacerbate viral-induced vaginal pathology.

A case of hypereosinophilic syndrome with STAT5b N642H mutation

Hypereosinophilia is defined as persistent eosinophilia (>1.5 × 10⁹/L). Hypereosinophilic syndrome (HES) is a term used to describe a group of disorders characterized by sustained hypereosinophilia associated with end-organ damage. Based on underlying molecular mechanism of eosinophilia, there are different subtypes of HES. Diagnosis of HES subtype can be challenging, especially in the absence of overt lymphoid/myeloid neoplasms or discernable secondary causes. Long-term outpatient follow-up with periodic complete blood count and repeated bone marrow biopsy may be needed to monitor disease activity. Somatic signal transducer and activation transcription 5b (STAT5b) N642H mutation was recently found to be associated with myeloid neoplasms with eosinophilia. We report a case of HES who presented with pulmonary embolism and acute eosinophilic pneumonia, found to have recurrent STAT5b N642H mutation by next-generation sequencing, suggesting possible underlying myeloid neoplasm.

Alarming Eosinophilia From Dobutamine Infusion

A 49-year-old male with a history of nonischemic heart failure with reduced ejection fraction, hypertension, diabetes was admitted for cardiogenic shock. Treatment started with a high dose of dobutamine infusion. While the patient’s volume status improved, his clinical status declined as he became febrile and hypotensive. He was found to have severe dobutamine-induced eosinophilia, corrected only upon dobutamine cessation and steroid administration. A comprehensive investigation ruled out other potential etiologies. Peripheral eosinophilia is a rare adverse effect associated with dobutamine, leading to a significant deterioration in already decompensated patients.

Targeting eosinophils in respiratory diseases: Biological axis, emerging therapeutics and treatment modalities

Eosinophils are bi-lobed, multi-functional innate immune cells with diverse cell surface receptors that regulate local immune and inflammatory responses. Several inflammatory and infectious diseases are triggered with their build up in the blood and tissues. The mobilization of eosinophils into the lungs is regulated by a cascade of processes guided by Th2 cytokine generating T-cells. Recruitment of eosinophils essentially leads to a characteristic immune response followed by airway hyperresponsiveness and remodeling, which are hallmarks of chronic respiratory diseases. By analysing the dynamic interactions of eosinophils with their extracellular environment, which also involve signaling molecules and tissues, various therapies have been invented and developed to target respiratory diseases. Having entered clinical testing, several eosinophil targeting therapeutic agents have shown much promise and have further bridged the gap between theory and practice. Moreover, researchers now have a clearer understanding of the roles and mechanisms of eosinophils. These factors have successfully assisted molecular biologists to block specific pathways in the growth, migration and activation of eosinophils. The primary purpose of this review is to provide an overview of the eosinophil biology with a special emphasis on potential pharmacotherapeutic targets. The review also summarizes promising eosinophil-targeting agents, along with their mechanisms and rationale for use, including those in developmental pipeline, in clinical trials, or approved for other respiratory disorders.

Hypersensitivity pneumonitis, allergic bronchopulmonary aspergillosis and other eosinophilic lung diseases

Hypersensitivity pneumonitis (HP) is traditionally classified into acute, subacute and chronic forms. A high index of suspicion and a detailed investigation into the patient's environment is the key to diagnosis and treatment of HP. Eosinophilic lung diseases can be broadly categorized as idiopathic (acute eosinophilic pneumonia, chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndromes), those with known cause (allergic bronchopulmonary aspergillosis, drugs, parasitic and non-parasitic infections), and those associated with other known lung diseases (asthma, interstitial lung diseases and lung cancers). A detailed review of drug intake, toxin exposures, and travel history is essential in the differential diagnosis of eosinophilic lung diseases.

Eosinophilic Pneumonia and Lymphadenopathy Associated With Vaping and Tetrahydrocannabinol Use

Idiopathic acute eosinophilic pneumonia is a rare and potentially life-threatening condition that is defined by bilateral pulmonary infiltrates and fever in the presence of pulmonary eosinophilia. It often presents acutely in previously healthy individuals and can be difficult to distinguish from infectious pneumonia. Although the exact etiology of idiopathic acute eosinophilic pneumonia remains unknown, an acute hypersensitivity reaction to an inhaled antigen is suggested, which is further supported by recent public health risks of vaping (electronic cigarette) use and the development of lung disease. In this case, a patient with a year-long history of vaping in conjunction with tetrahydrocannabinol cartridge use who was diagnosed with idiopathic acute eosinophilic pneumonia with associated bilateral hilar lymphadenopathy is described.

Spectrum of imaging findings in pulmonary infections. Part 2: Fungal, mycobacterial, and parasitic

Chest radiography is generally the first imaging modality used for the evaluation of pneumonia. It can establish the presence of pneumonia, determine its extent and location, and assess the response to treatment. Computed tomography is not used for the initial evaluation of pneumonia, but it may be used when the response to treatment is unusually slow. It helps to identify complications, detect any underlying chronic pulmonary disease, and characterise complex pneumonias. Although not diagnostic, certain imaging findings may suggest a particular microbial cause over others. Knowledge of whether pneumonia is community-acquired or nosocomial, as well as the age and immune status of the patient, can help to narrow the differential diagnoses. The purpose of this article is to briefly review the various pulmonary imaging manifestations of pathogenic organisms. This knowledge, along with the clinical history and laboratory investigations of the patient, may help to guide the treatment of pneumonia.

Diagnosis of soil-transmitted helminth infections. An unsolved problemin the omics era

Infections caused by Strongyloides stercoralis and other soil-transmitted worms such as hookworms (Necator americanus and Ancylostoma duodenale) represent a major problem worldwide, especially in developing areas. They are difficult to suspect clinically since they produce non-specific and often overlapping signs and symptoms. Likewise, their long prepatent periods hamper the detection of parasitic structures. Microscopic diagnosis is still the most commonly used tool in healthcare laboratories but it is still far from being the ideal technique to detect these infections due to its low sensitivity. In addition, these nematodes have strong morphologic similarities and consequently microbiological diagnosis remains a challenge. Serology has made progress in the diagnosis of S. stercoralis infection but this option is not yet available for hookworms. Molecular biology techniques have been shown to slightly increase this lack of sensitivity, but as with other parasitic infections, they are not currently available for use in clinical microbiology laboratories. Supplement information: This article is part of a supplement entitled «SEIMC External Quality Control Programme. Year 2016», which is sponsored by Roche, Vircell Microbiologists, Abbott Molecular and Francisco Soria Melguizo, S.A. © 2019 Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosasy Microbiología Clínica. All rights reserved.

Critical role of CCL4 in eosinophil recruitment into the airway

BACKGROUND

Excessive eosinophil airway infiltration is a clinically critical condition in some cases. Eosinophilic pneumonia (EP) is a pulmonary condition involving eosinophil infiltration of the lungs. Although several chemokines, including eotaxin-1 (CCL11), RANTES (CCL5) and macrophage inflammatory protein 1β (MIP-1β or CCL4), have been detected in bronchoalveolar lavage fluid (BALF) from patients with EP, the pathophysiological mechanisms underlying EP, including potential relationships between eosinophils and CCL4, have not been fully elucidated.

OBJECTIVE

To examine the involvement of CCL4 in eosinophilic airway inflammation.

METHODS

We analysed supernatants of activated eosinophils and BALF from 16 patients with eosinophilic pneumonia (EP). Further, we examined the effects of CCL4 on eosinophil functions in vitro and those of anti-CCL4 neutralizing antibody in an in vivo model.

RESULTS

We found that purified human eosinophils stimulated with IL-5 predominantly secreted CCL4 and that patients with EP had elevated CCL11 and CCL4 levels in BALF compared with samples from individuals without EP. Because CCL4 levels were more strongly correlated with eosinophil count and expression of eosinophil granule proteins than CCL11, in vitro experiments using purified eosinophils concentrated on the former chemokine. Interestingly, CCL4 acted as a chemoattractant for eosinophils. In a mouse model, administration of a CCL4-neutralizing antibody attenuated eosinophilic airway infiltration and airway hyperresponsiveness.

CONCLUSIONS AND CLINICAL RELEVANCE

Overall, these findings highlight an important role of CCL4 in the mechanisms underlying eosinophil recruitment into the airway and may provide a novel insight into this potential therapeutic target.

Chronic eosinophilic pneumonia: clinical perspectives

Chronic eosinophilic pneumonia (CEP) is an eosinophilic lung disease that is typically diagnosed by a triad of clinical symptoms including pulmonary symptoms, eosinophilia and characteristic radiographic abnormalities. It requires a high index of suspicion given its overlap with other eosinophilic conditions and lack of a specific diagnostic test. The diagnosis is made after careful consideration of other secondary causes of eosinophilia, such as infectious, drugs, or toxic etiologies. CEP generally responds rapidly to treatment, which primarily consists of corticosteroid therapy, but relapses are common. Novel therapies are being explored as more information is being discovered about the pathophysiology of eosinophilic disease processes. Close follow-up is important given the difficulty in weaning patients from glucocorticoids with many patients developing sequelae of chronic glucocorticoid therapy. Therefore, exploring alternative treatments is of upmost importance.

Basic Bronchoscopy: Technology, Techniques, and Professional Fees

Flexible bronchoscopy has evolved over the last few decades, allowing chest physicians to use advanced high-definition scopes to inspect the airways and perform various sampling techniques. Although the techniques of basic bronchoscopic sampling have not changed dramatically, documentation requirements, coding, and billing have become more complex and require a better understanding on the part of the proceduralists and practice administrators. Areas in need of attention include learning about the multiple endoscopy rule, appropriate use of modifiers, and recent changes to the Current Procedural Terminology codes, associated work relative value units for moderate sedation, and therapeutic aspiration of secretions. This article describes basic bronchoscopic procedures and the principles needed for their coding and billing.

Chronic eosinophilic pneumonia after trastuzumab and radiation therapy for breast cancer: A case report

RATIONALE

Chronic eosinophilic pneumonia (CEP) is rare and an idiopathic disorder. The disease has been associated with drugs, infection, or irradiation, and its relationship with asthma remains unclear.

PATIENT CONCERNS

We reported a case of a 49-year-old female patient after trastuzumab and radiation therapy for breast cancer. Two months after radiation treatment, the patient complained of productive cough, progressive breathlessness, occasional wheezing, and left pectoralgia.

DIAGNOSES

Computed tomography (CT) scan revealed infiltrates in lungs. Without evidence of infection, marked increased eosinophils in a transbronchial biopsy performed from the left upper lobe confirmed the diagnosis of CEP after trastuzumab and radiation therapy.

INTERVENTIONS

The patient was started with oral prednisone at 0.5 mg/kg/day.

OUTCOMES

A CT scan of the chest obtained 2 weeks after steroid treatment showed diminishment of the lesions, and at the 6-month follow-up, the patient had no complaints of discomfort with no relapse of pulmonary lesions.

LESSONS

Physicians should consider CEP as a diagnosis in patients who have had previous exposure to trastuzumab and radiation therapy, especially with a history of asthma. Timely diagnosis and treatment may benefit these patients.

Ascaris Larval Infection and Lung Invasion Directly Induce Severe Allergic Airway Disease in Mice

Ascaris lumbricoides (roundworm) is the most common helminth infection globally and a cause of lifelong morbidity that may include allergic airway disease, an asthma phenotype. We hypothesize that Ascaris larval migration through the lungs leads to persistent airway hyperresponsiveness (AHR) and type 2 inflammatory lung pathology despite resolution of infection that resembles allergic airway disease. Mice were infected with Ascaris by oral gavage. Lung AHR was measured by plethysmography and histopathology with hematoxylin and eosin (H&E) and periodic acid-Schiff (PAS) stains, and cytokine concentrations were measured by using Luminex Magpix. Ascaris-infected mice were compared to controls or mice with allergic airway disease induced by ovalbumin (OVA) sensitization and challenge (OVA/OVA). Ascaris-infected mice developed profound AHR starting at day 8 postinfection (p.i.), peaking at day 12 p.i. and persisting through day 21 p.i., despite resolution of infection, which was significantly increased compared to controls and OVA/OVA mice. Ascaris-infected mice had a robust type 2 cytokine response in both the bronchoalveolar lavage (BAL) fluid and lung tissue, similar to that of the OVA/OVA mice, including interleukin-4 (IL-4) (P < 0.01 and P < 0.01, respectively), IL-5 (P < 0.001 and P < 0.001), and IL-13 (P < 0.001 and P < 0.01), compared to controls. By histopathology, Ascaris-infected mice demonstrated early airway remodeling similar to, but more profound than, that in OVA/OVA mice. We found that Ascaris larval migration causes significant pulmonary damage, including AHR and type 2 inflammatory lung pathology that resembles an extreme form of allergic airway disease. Our findings indicate that ascariasis may be an important cause of allergic airway disease in regions of endemicity.

Late post-kidney transplant Strongyloides hyperinfection syndrome

Disseminated strongyloidiasis is a potentially life-threatening infection in organ transplant recipients that typically occurs within the first 6 months of transplantation. We discuss a patient from the Appalachia region of Virginia who appeared to acquire Strongyloides stercoralis domestically years after kidney transplantation and then develop disseminated strongyloidiasis.

Radiation Pneumonitis with Eosinophilic Alveolitis in a Lung Cancer Patient

A 59-year-old woman suffering from dry cough and dyspnea was admitted to our hospital. She had undergone concurrent chemo-radiotherapy five months earlier. Chest computed tomography revealed bilateral ground-glass opacities extending outside the irradiated lung field. Her eosinophil numbers were increased in both the peripheral blood and the bronchoalveolar lavage fluid; therefore, she was diagnosed with radiation pneumonitis accompanied by eosinophilic alveolitis. Steroid therapy promptly improved the pneumonitis. Radiation pneumonitis accompanied by eosinophilic alveolitis extending outside the irradiated field is rare. Bronchoalveolar lavage is useful for a diagnosis, and steroid therapy is effective for treatment.

Changes in pulmonary function of residents in Sanriku Seacoast following the tsunami disaster from the Great East Japan Earthquake

BACKGROUND

Residents in the district struck by the Great East Japan Earthquake Tsunami (GEJET) suffered from adverse living conditions and various pulmonary diseases.

OBJECTIVES

To evaluate the influence of GEJET, we performed serial assessment of pulmonary function of approximately 10,000 residents in the district struck by GEJET.

METHODS

Using a spirometer, we assessed the pulmonary function of approximately 10,000 residents older than 18 years in the Sanriku seacoast, which was struck by the tsunami. Measurements were performed in 2011 and 2012.

RESULTS

We compared FVC (forced vital capacity) % pred. and FEV1 (forced expiratory volume in 1second) % pred. of subjects between 2011 and 2012, by serial spirometry. Of the 7053 subjects studied, including 2611 men and 4442 women, FVC% pred. and FEV1% pred. were significantly higher in 2012 than in 2011. Physical indices including height, body weight and the body mass index (BMI) did not change significantly during this period. Smoking prevalence changed significantly between 2010, 2011, and 2012. Both FVC% pred. and FEV1% pred. of subjects who had quit smoking increased significantly on spirometry carried out in 2012, compared with those in 2011.

CONCLUSIONS

The pulmonary function expressed as FVC% pred. and FEV1% pred. were significantly higher in 2012 than in 2011 among the subjects studied. The changes in the smoking status may be one of the reasons for the increase in values observed. However, other undetermined factors during recovery from a disaster might have resulted in improved pulmonary function.

Imported gnathostomiasis manifesting as cutaneous larva migrans and Löffler's syndrome

Here, we report an unusual case of invasive gnathostomiasis in a returning traveller, with a shifting pattern of relapsing cutaneous disease. The previously fit and well 32-year-old man first presented with serpiginous, pruriginous erythematous tracks characteristic of cutaneous larva migrans shortly after returning from South-East Asia. He was systemically well with no other symptoms. After ivermectin therapy, he re-presented with respiratory symptoms, peripheral eosinophilia and transient pulmonary infiltrates; the classic triad of Löffler's syndrome associated with invasive helminth infection. Gnathostoma spinigerum immunoblot was positive. After a second round of ivermectin therapy his respiratory symptoms resolved, but the patient's cutaneous disease relapsed repeatedly over months, with migratory erythematous swellings appearing and settling after a few days. He was treated with a 21-day course of albendazole and is lesion free at 40 weeks post initial presentation.

Soil-transmitted helminth infections

More than a quarter of the world's population is at risk of infection with the soil-transmitted helminths Ascaris lumbricoides, hookworm (Ancylostoma duodenale and Necator americanus), Trichuris trichiura, and Strongyloides stercoralis. Infected children and adults present with a range of medical and surgical conditions, and clinicians should consider the possibility of infection in individuals living in, or returning from, endemic regions. Although safe and effective drugs are donated free to endemic countries, only half of at-risk children received treatment in 2016. This Seminar describes the epidemiology, lifecycles, pathophysiology, clinical diagnosis, management, and public health control of soil-transmitted helminths. Previous work has questioned the effect of population-level deworming; however, it remains beyond doubt that treatment reduces the severe consequences of soil-transmitted helminthiasis. We highlight the need for refined diagnostic tools and effective control options to scale up public health interventions and improve clinical detection and management of these infections.

A Man in His 20s With Diffuse Lung Opacities and Acute Respiratory Failure After Hookah Smoking

A man in his 20s with no medical history presented with 2 days of progressively worsening shortness of breath accompanied by subjective fevers, chills, body aches, decreased appetite, night sweats, and cough producing nonbloody sputum. He denied childhood lung diseases, allergies, or a family history of lung disease. He did not smoke cigarettes but had smoked hookah in Saudi Arabia before moving to the United States 1 month before presentation and had restarted 2 days before the start of symptoms. He denied travel outside of the northeastern United States. He did not take medications, use illicit drugs, or engage in high-risk behavior.

Raising awareness of bronchiectasis in primary care: overview of diagnosis and management strategies in adults

Bronchiectasis is a chronic lung disease characterised by recurrent infection, inflammation, persistent cough and sputum production. The disease is increasing in prevalence, requiring a greater awareness of the disease across primary and secondary care. Mild and moderate cases of bronchiectasis in adults can often be managed by primary care clinicians. Initial assessments and long-term treatment plans that include both pharmacological and non-pharmacological treatments, however, should be undertaken in collaboration with a secondary care team that includes physiotherapists and specialists in respiratory medicine. Bronchiectasis is often identified in patients with other lung diseases, such as chronic obstructive pulmonary disease, asthma, and in a lesser but not insignificant number of patients with other inflammatory diseases, such as rheumatoid arthritis and inflammatory bowel disease. Overall goals of therapy are to prevent exacerbations, improve symptoms, improve quality of life and preserve lung function. Prompt treatment of exacerbations with antibiotic therapy is important to limit the impact of exacerbations on quality of life and lung function decline. Patient education and cooperation with health-care providers to implement treatment plans are key to successful disease management. It is important for the primary care provider to work with secondary care providers to develop an individualised treatment plan to optimise care with the goal to delay disease progression. Here, we review the diagnosis and treatment of bronchiectasis with a focus on practical considerations that will be useful to primary care.

The Role and Immunobiology of Eosinophils in the Respiratory System: a Comprehensive Review

The eosinophil is a fully delineated granulocyte that disseminates throughout the bloodstream to end-organs after complete maturation in the bone marrow. While the presence of eosinophils is not uncommon even in healthy individuals, these granulocytes play a central role in inflammation and allergic processes. Normally appearing in smaller numbers, higher levels of eosinophils in the peripheral blood or certain tissues typically signal a pathologic process. Eosinophils confer a beneficial effect on the host by enhancing immunity against molds and viruses. However, tissue-specific elevation of eosinophils, particularly in the respiratory system, can cause a variety of short-term symptoms and may lead to long-term sequelae. Eosinophils often play a role in more commonly encountered disease processes, such as asthma and allergic responses in the upper respiratory tract. They are also integral in the pathology of less common diseases including eosinophilic pneumonia, allergic bronchopulmonary aspergillosis, hypersensitivity pneumonitis, and drug reaction with eosinophilia and systemic symptoms. They can be seen in neoplastic disorders or occupational exposures as well. The involvement of eosinophils in pulmonary disease processes can affect the method of diagnosis and the selection of treatment modalities. By analyzing the complex interaction between the eosinophil and its environment, which includes signaling molecules and tissues, different therapies have been discovered and created in order to target disease processes at a cellular level. Innovative treatments such as mepolizumab and benralizumab will be discussed. The purpose of this article is to further explore the topic of eosinophilic presence, activity, and pathology in the respiratory tract, as well as discuss current and future treatment options through a detailed literature review.

[Clinical approach to imported eosinophilia]

Eosinophilia is a common finding in international travelers and immigrants, being an helmintic infection its main etiology. The positive predictive value of eosinophilia for an helmintosis is low in travellers. Eosinophilia may be an incidental finding, or symptomatic, and it represents a clinical challenge due to the low sensitivity and specificity of direct and indirect parasitological diagnostic tests, respectively. It requires a structured approach based on geographical areas, environmental exposures and behavioral risks, and associated symptoms. The initial assessment should include a comprehensive and tailored anamnesis and physical examination, basic laboratory tests, a complete parasitological examination of stool samples and a Strongyloides stercoralis serology, supplemented with other explorations guided by epidemiological and clinical suspicion. Empiric treatment with albendazole and/or ivermectin (plus praziquantel if risk of schistosomiasis) is an option for unidentified persistent eosinophilia after study, and in persons in whom a proper assessment or follow-up can not be assured. In patients at risk for estrongiloidosis who are candidates for immunosuppressive therapies, it is indicated a prior screening and treatment to prevent a future hyperinfestation syndrome.

Eosinophilia

Eosinophilia is defined as elevation of eosinophils in the bloodstream (450-550 cell/μL). There are many reasons for eosinophilia to exist, including parasitic disease, allergic disease, autoimmune, connective tissue disease, rheumatologic disease, primary eosinophilia such as hypereosinophilic syndrome, and as part of a malignant state. Primary care physicians should have an understanding of the variety of diseases or situations that can produce eosinophilia and know in what setting referral to specialty care may be warranted.

Löffler syndrome on a Louisiana pig farm

Löffler syndrome, a fulminant eosinophilic pneumonitis associated with the larval migratory phase of human parasites, is rarely reported in the United States. A previously healthy 8-year-old male was hospitalized with tachypnea, cough, hypoxemia, and fever of one week's duration. History revealed exposure to pigs on his family's farm in southernmost Louisiana, where the patient was responsible for cleaning the farm's pigpens. His fingernails were soiled and extremely short, with the edge of the nail bed exposed secondary to onychophagia. Laboratory evaluation demonstrated peripheral eosinophilia (39%), pulmonary eosinophilia (86%), high total IgE, diffuse reticulonodular lung opacities, and mixed obstructive and restrictive pulmonary function pattern. Systemic corticosteroids were initiated for his acute respiratory insufficiency and produced rapid clinical improvement. Serum Ascaris-specific IgE was markedly elevated and he was treated with albendazole. An extensive evaluation for other infectious and allergic etiologies was negative. A site visit to the family farm and laboratory investigation was coordinated with the Louisiana Animal Disease Diagnostic Laboratory at LSU. Ascaris suum eggs were detected in fresh pig feces and in the soil immediately surrounding the pens. Ascariasis should be considered even in the absence of travel history, especially in swine raising areas that are endemic for Ascaris in pigs, such as the southeastern United States. Onychophagia is a highly probable mechanism of zoonotic fecal-oral transmission in this case, and such habits could lead to continual reinfection. Systemic corticosteroids were effective in treating the patient's acute respiratory compromise due to Löffler syndrome.

Pulmonary eosinophilia associated to treatment with natalizumab

Natalizumab (Tysabri^®) is a leukocytes chemotaxis inhibitor that decreases the leukocytes passage through the hematoencephalic barrier and it is currently used in relapsing-remitting forms of multiple sclerosis (MS). We present a patient with allergic rhinoconjunctivitis diagnosed with MS who started treatment with natalizumab. She began to show mild asthmatic symptoms until she needed admission to the hospital due to respiratory insufficiency. Blood tests showed peripheral eosinophilia and the thoracic computed tomography scan demonstrated pulmonary infiltrates. The bronchoscopy with the bronchoalveolar lavage resulted in eosinophilic alveolitis. No evidence of bacterial, fungal and parasitic infection, connective tissue disease, or vasculitis were observed. After discontinuation of natalizumab, the patient improved without other treatments. As MS is a prevalent disease and the use of natalizumab is increasing, we consider important to point out that this drug can be associated with pulmonary eosinophilia, especially in patients with allergic rhinoconjunctivitis or asthma.