Flavored Cigar Smoking Induces Acute Eosinophilic Pneumonia

Acute Eosinophilic Pneumonia. Causes, Diagnosis, and Management

Acute eosinophilic pneumonia (AEP) is an uncommon acute respiratory illness of varying severity that includes presentation as acute respiratory distress syndrome with fatal outcome. AEP may be idiopathic, but identifiable causes include smoking and other inhalational exposures, medications, and infections. The pathogenesis of AEP is poorly understood but likely varies depending on the underlying cause. Airway epithelial injury, endothelial injury, and release of IL-33 are early events that subsequently promote eosinophil recruitment to the lung; eosinophilic infiltration and degranulation appear to mediate subsequent lung inflammation and associated clinical manifestations. Crucial for the diagnosis are the demonstration of pulmonary eosinophilia in the BAL fluid and the exclusion of other disease processes that can present with acute pulmonary infiltrates. Although peripheral blood eosinophilia at initial presentation may be a clue in suggesting the diagnosis of AEP, it may be absent or delayed, especially in smoking-related AEP. Optimal management of AEP depends on the recognition and elimination of the underlying cause when identifiable. The cessation of the exposure to the inciting agent (e.g., smoking), and glucocorticoids represent the mainstay of treating AEP of noninfectious origin. If AEP is recognized and treated in a timely manner, the prognosis is generally excellent, with prompt and complete clinical recovery, even in those patients manifesting acute respiratory failure.

Elevated Periostin Concentrations in the Bronchoalveolar Lavage Fluid of Patients with Eosinophilic Pneumonia

BACKGROUND

Eosinophilic pneumonia (EP) is characterized by massive pulmonary infiltration by eosinophils. Although serum periostin is a novel marker for eosinophil-dominant asthma, the upregulation of periostin in the airway of asthmatics is controversial. In this study, we examined whether periostin concentrations are elevated in the bronchoalveolar lavage fluid (BALF) of patients with EP.

METHODS

BAL was performed in healthy volunteers and in patients with acute eosinophilic pneumonia (AEP), chronic eosinophilic pneumonia (CEP), and sarcoidosis. The periostin concentrations in the BALF were measured.

RESULTS

The periostin concentration in the BALF increased significantly with pulmonary eosinophil ia and was higher in AEP and CEP patients than in healthy volunteers and sarcoidosis patients, even after adjusting the albumin concentration. In pulmonary eosinophilia, the periostin concentration correlated with the eosinophil and lymphocyte counts, the concentration of albumin, and the concentration of cytokines such as IL-5, IL-13, and transforming growth factor β1.

CONCLUSIONS

Although some blood leakage may be involved in the elevation of periostin in the BALF of EP, periostin can be induced locally, at least in part. Therefore, periostin may play a role in the development of EP.

Acute eosinophilic pneumonia in the deployed military setting

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.

Eosinophilic Lung Diseases

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.

Flavored Tobacco Products in the United States: A Systematic Review Assessing Use and Attitudes

OBJECTIVES

We systematically reviewed research examining use of and attitudes toward nonmenthol-flavored tobacco products to provide information relevant to a decision to regulate these products in the future.

METHODS

To identify eligible studies, we searched PubMed, CINHAL, Embase, LILACS, and PsycINFO on September 19, 2013, without date restrictions. We obtained additional studies via gray literature searches, expert contacts, and hand-searching citations of included articles. We included participants of all ages. We conducted a qualitative synthesis for included studies.

RESULTS

The 32 studies included in this review exhibited substantial heterogeneity and were of varied methodological quality. Findings from observational, experimental, and quasiexperimental studies suggest that flavored tobacco use is associated with young age and that consumers may perceive flavored products more favorably than nonflavored products. Evidence from qualitative studies indicates that flavoring in tobacco is viewed favorably by users and nonusers of these products.

CONCLUSIONS

The Food and Drug Administration has expressed interest in regulating flavored tobacco products. This systematic review strengthens the evidence base relating to this issue by synthesizing the literature from the United States on the use of and attitudes toward flavored tobacco. To address gaps in the literature, more research is needed to understand how flavoring impacts tobacco use over time. The evidence base would further be strengthened with the collection of brand-, flavor-, and product-specific data.

A case of eosinophilic pneumonia simultaneously diagnosed in a patient and a tame cat: a case report

Introduction

Chronic eosinophilic pneumonia is an idiopathic disorder of unknown etiology. Corticosteroid treatment provides a good response but recurrence frequently occurs after tapering of corticosteroid. Chronic eosinophilic pneumonia occurs predominantly in middle-aged women and non-cigarette smokers, which leads to the speculation that environmental antigens, particularly in the home, contribute to the etiology.

Case presentation

A 66-year-old Japanese woman was given a diagnosis of chronic eosinophilic pneumonia for 8 years and was treated with prednisone. She developed respiratory symptoms again with tapering of prednisone (10mg/day). A chest radiograph revealed patchy shadows in her bilateral upper lung fields, and bronchoalveolar lavage fluid revealed marked eosinophilia. Based on negative findings for other causes of eosinophilia, the diagnosis of the recurrence of chronic eosinophilic pneumonia was established. She was treated with prednisone (20mg/day), which demonstrated rapid improvement. Around the same time, her tame cat developed oral breathing, tachypnea and peripheral eosinophilia. Chest radiography of the cat revealed ground-glass opacity in its bilateral upper lung fields. Eosinophilic pneumonia was also diagnosed in the cat that was treated by prednisone (3mg/day). Since eosinophilic pneumonia was diagnosed simultaneously in the patient and her tame cat, it can be suggested that inhaled environmental antigens in the home caused the eosinophilic pneumonia. After moving out of her home, she and the cat had no recurrence of eosinophilic pneumonia.

Conclusions

Although chronic eosinophilic pneumonia is an idiopathic disorder of unknown etiology, our case suggests that inhaled environmental antigens in the home may be associated with the causes of chronic eosinophilic pneumonia. A pet’s disease may give us an important clue for the therapeutic approach of the owner’s disease.

Eosinophilic pneumonias

This review starts with discussions of several infectious causes of eosinophilic pneumonia, which are almost exclusively parasitic in nature. Pulmonary infections due specifically to Ascaris, hookworms, Strongyloides, Paragonimus, filariasis, and Toxocara are considered in detail. The discussion then moves to noninfectious causes of eosinophilic pulmonary infiltration, including allergic sensitization to Aspergillus, acute and chronic eosinophilic pneumonias, Churg-Strauss syndrome, hypereosinophilic syndromes, and pulmonary eosinophilia due to exposure to specific medications or toxins.

The relationship between the clinical course and cytokine in a patient with cigarette smoking-induced acute eosinophilic pneumonia - A case report

A 19-year-old female was admitted to our hospital because of a sudden onset fever and cough, and she was diagnosed to have acute eosinophilic pneumonia (AEP). The cause was thought to be cigarette smoking, because she had started smoking just before the development of AEP and her condition improved after cigarette smoking cessation, without corticosteroid treatment. The cytokines which are thought to be involved in eosinophilic accumulation in the lungs were analyzed using bronchoalveolar lavage fluid (BALF) and serum. Of the analyzed cytokines, only regulated on activation, normal T cell expressed and secreted (RANTES) increased in the serum after the improvement. RANTES is a unique chemokine which attracts not only eosinophils, but also T cells. Interestingly, in this case, the eosinophil count in the blood increased in parallel with the lymphocyte count after the improvement. These findings are interesting because it may help to understand the pathogenesis of AEP and the role of RANTES.

Smoking-related interstitial lung diseases

Cigarette smoke, a toxic collection of thousands of chemicals generated from combustion of tobacco, is recognized as the primary causative agent of certain diffuse interstitial and bronchiolar lung diseases. Most patients afflicted with these disorders are cigarette smokers, and smoking cessation has been shown to be capable of inducing disease remission and should occupy a pivotal role in the management of all smokers with these diffuse lung diseases. The role of pharmacotherapy with corticosteroids or other immunomodulating agents is not well established but may be considered in patients with progressive forms of smoking-related interstitial lung diseases.