Cigarette smoking-induced acute eosinophilic pneumonia: a case report including a provocation test

Smoking-associated interstitial lung disease: update and review

INTRODUCTION

Smoking-associated interstitial lung disease manifests as several heterogeneous disorders involving the airways, pleura, and lung parenchyma with various radiological patterns. The clinical history, radiologic, and pathologic findings are important to distinguish these more uncommon diseases. A multidisciplinary approach is recommended for diagnosis and to manage these conditions appropriately.

AREAS COVERED

This review provides an overview of the epidemiology, risk factors, pathogenesis, clinical features, diagnosis, and treatment of acute eosinophilic pneumonia, e-cigarettes, or vaping associated lung injury, respiratory bronchiolitis interstitial lung disease, desquamative interstitial pneumonitis, pulmonary Langerhans cell histiocytosis, idiopathic pulmonary fibrosis, and combined pulmonary fibrosis emphysema.

EXPERT OPINION

Cigarette smoking is associated with a variety of pathologic conditions that affect the airways and lungs. E-cigarette use and vaping present new challenges to the clinician. Consensus between the clinical, radiographic, and pathologic findings is important in identifying and differentiating between the various entities to properly diagnose smoking-related interstitial lung diseases discussed in this review.

[Acute eosinophilic pneumonia and illicit psychoactive substance use]

Illicit psychoactive substance (IPAS) use can lead to a number of respiratory complications, including acute eosinophilic pneumonia (AEP). Systematic literature review of data on AEP in IPAS users (cannabis, cocaine, heroin and amphetamine). Of two cases of cannabis and tobacco users reported to have developed AEP, one, a teenage15 year old boy presented with acute respiratory distress syndrome (ARSD) which necessitated extracorporeal membrane oxygenation (ECMO). Five cases of AEP in cocaine smokers (crack) are reported, one of which was fatal. The patient presented with acute pulmonary edema and ARDS which progressed to ventricular fibrillation and asystole. A 24-year-old woman presented with AEP after repeated inhalation of heroin. Finally, a case of an amphetamine abuser who developed AEP and ARDS after amphetamine inhalation is reported. The time between the first IPAS use and admission in cases reported ranged from 7 days to 4 years, while time between the last IPAS use and admission was short (less than 15 days). IPAS use must be sought in case of AEP, especially in young adults, and practitioners must advise and help users to stop their consumption.

Unexpected Outcome of Daptomycin-induced Eosinophilic Pneumonia: Rarity Within a Rarity

Eosinophilic pneumonia comprises a group of lung diseases in which eosinophils appear in increased numbers in the lungs and sometimes in the bloodstream. Among several causes of pulmonary eosinophilia, drug-induced pulmonary eosinophilia and subsequent pneumonia is a well-known side effect of many medications. Daptomycin is now being increasingly recognized culprit medication in patients with eosinophilic pneumonia. Here we present a patient with daptomycin-induced acute eosinophilic pneumonia, who had an unusual response to usual treatment.

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.

[The respiratory effects of smoking]

A marked increase in the morbidity and mortality of a large number of broncho-pulmonary diseases has been documented in relation to smoking. The influence of tobacco smoking on various respiratory conditions. is discussed: incidence, severity or natural history modification of some respiratory illnesses: obstructive lung diseases (COPD, asthma), lung cancer, bacterial, viral respiratory infections, with the impact of smoking on tuberculosis. Finally, the relationship of tobacco with diffuse interstitial lung disease: protective role of smoking (controversial in sarcoidosis, real in hypersensitivity pneumonitis). The benefits of smoking cessation are described.

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.

Chronic Cigarette Smoke Mediated Global Changes in Lung Mucoepidermoid Cells: A Phosphoproteomic Analysis

Proteomics analysis of chronic cigarette smoke exposure is a rapidly emerging postgenomics research field. While smoking is a major cause of lung cancer, functional studies using proteomics approaches could enrich our mechanistic understanding of the elusive lung cancer global molecular signaling and cigarette smoke relationship. We report in this study on a stable isotope labeling by amino acids in cell culture-based quantitative phosphoproteomic analysis of a human lung mucoepidermoid carcinoma cell line, H292 cells, chronically exposed to cigarette smoke. Using high resolution Orbitrap Velos mass spectrometer, we identified the hyperphosphorylation of 493 sites, which corresponds to 341 proteins and 195 hypophosphorylated sites, mapping to 142 proteins upon smoke exposure (2.0-fold change). We report differential phosphorylation of multiple kinases, including PAK6, EPHA4, LYN, mitogen-activated protein kinase, and phosphatases, including TMEM55B, PTPN14, TIGAR, among others, in response to chronic cigarette smoke exposure. Bioinformatics analysis revealed that the molecules differentially phosphorylated upon chronic exposure of cigarette smoke are associated with PI3K/AKT/mTOR and CDC42-PAK signaling pathways. These signaling networks are involved in multiple cellular processes, including cell polarity, cytoskeletal remodeling, cellular migration, protein synthesis, autophagy, and apoptosis. The present study contributes to emerging proteomics insights on cigarette smoke mediated global signaling in lung cells, which in turn may aid in development of precision medicine therapeutics and postgenomics biomarkers.

Acute Eosinophilic Pneumonia: Correlation of Clinical Characteristics With Underlying Cause

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.

Spectrum of Smoking-related Lung Diseases: Imaging Review and Update

There is increased awareness of smoking-related lung diseases other than lung cancer and chronic obstructive pulmonary disease. Concurrently, there is general acceptance that there is difficulty in establishing a specific diagnosis of smoking-related interstitial lung disease (ILD), as many patients may not undergo biopsy to facilitate a specific histopathologic diagnosis. Cases that do proceed to biopsy may demonstrate multiple abnormalities, and histologic overlap between different disease processes may confound the picture. This review outlines the key aspects of smoking-related lung disease, including entities secondary to smoking-related lung inflammation such as respiratory bronchiolitis-ILD, desquamative idiopathic pneumonia, and pulmonary Langerhans cell histiocytosis, as well as chronic fibrosing lung diseases strongly associated with cigarette smoke including idiopathic pulmonary fibrosis, combined pulmonary fibrosis and emphysema, nonspecific interstitial pneumonia, and rheumatoid arthritis-ILD. The focus will be on incorporation of clinical findings, key pulmonary function testing parameters, high-resolution computer tomography (HRCT) findings, and pathologic correlates in refining the differential diagnosis and differentiating between the various entities.

Acute eosinophilic pneumonia following recent cigarette smoking

In this report we describe the case of an 18 year old female who presented with fever, shortness of breath, and chest pain. Chest X-ray revealed diffuse bilateral infiltrates and eosinophilia was reported from her broncholaveolar lavage (BAL) fluid. She started smoking 3 weeks prior to the onset of symptoms and based on her clinical presentation, BAL findings and dramatic improvement, acute eosinophilic pneumonia (AEP) was diagnosed.

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.

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

INTRODUCTION

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

CASE STUDY

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

RESULTS

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

CONCLUSION

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

Acute eosinophilic pneumonia leading to acute respiratory failure in a current systemic corticosteroid user

A 69-year-old female patient visited the emergency room with fever (38.3℃) and dyspnea. She had been taking prednisolone (5 mg once per day) and methotrexate (2.5 mg once per week) for rheumatoid arthritis for 2 years. Chest computed tomography (CT) showed bilateral, multifocal ground glass opacity with interlobular septal thickening. Peripheral blood leukocyte count was 6,520/mm(3) (neutrophils, 77.4%; eosinophils, 12.1%). During the night, mechanical ventilation was initiated due to the development of severe hypoxemia. Bronchoalveolar lavage fluid showed a high proportion of eosinophils (49%). Her symptoms improved dramatically after commencement of intravenous methylprednisolone therapy. This is the first report of idiopathic acute eosinophilic pneumonia developing in a current user of systemic corticosteroids.