Eosinophilic Penumonia

Eosinophilic Eosinophilic PenumoniaPenumonia

Wael BatobaraWael Batobara

HistoryHistory• 80 y Male X smoker 50y 15pp80 y Male X smoker 50y 15pp

• Childhood Bronchial AstmaChildhood Bronchial Astma

• Non resolving SOB , Cough , Wheeze 3/52Non resolving SOB , Cough , Wheeze 3/52

• Orthopnea But no PNDOrthopnea But no PND

HistoryHistory• Low grade fever , minimal sputum Low grade fever , minimal sputum

• No chest pain or leg painNo chest pain or leg pain

• No hematuria , joint swelling or painNo hematuria , joint swelling or pain

• No runny nose ,post nasal drip, heart burn No runny nose ,post nasal drip, heart burn

HistoryHistory• No change in environment No change in environment

• No contact with sick person , No petsNo contact with sick person , No pets

• Increased use of bronchodilator without Increased use of bronchodilator without responseresponse

• Seen at Selkerik treated with Abx without Seen at Selkerik treated with Abx without responseresponsetransferred to HSC Dec 17thtransferred to HSC Dec 17th

HistoryHistory• PMHPMH : Childhood Asthma : Childhood Asthma

Infrequent attacks Infrequent attacks

No Intubations or ICU admissionsNo Intubations or ICU admissions

HTN ,DM with proteinuriaHTN ,DM with proteinuria

Osteoprosis & Chronic XerosisOsteoprosis & Chronic Xerosis

No IHD , CHF No IHD , CHF

HistoryHistory

• PSH PSH :: TURP TURP

• RxRx : : Adavir , Terbutaline , Metformine Adavir , Terbutaline , Metformine

,Ramipril , Alendronate , Vit D , ,Ramipril , Alendronate , Vit D ,

Ca & ECASA Ca & ECASA

ExaminationExamination

• Temp 37.8 RR18 Sat 90-95 on 2-5 lit. O2Temp 37.8 RR18 Sat 90-95 on 2-5 lit. O2

• BP 130/70 HR 90BP 130/70 HR 90

• ENT : no erythema ,post nasal dripENT : no erythema ,post nasal drip

• Chest : resonant ,Good BSChest : resonant ,Good BS

bilateral Wheeze , minimal cracklesbilateral Wheeze , minimal crackles

ExaminationExamination• CVS : JVP N S1+S2+0 CVS : JVP N S1+S2+0

• Abd & LL NAbd & LL N

• No skin rash , arthritis No skin rash , arthritis

• CNS NADCNS NAD

InvestigationsInvestigations

• CBC WBC 14.4 Eosinophil 44%CBC WBC 14.4 Eosinophil 44%

Hb 120 MCV N & Plt NHb 120 MCV N & Plt N

• Coagulation NCoagulation N

• BUN , Creat & lytes NBUN , Creat & lytes N

• Cardiac enzymes & EKG NCardiac enzymes & EKG N

InvestigationsInvestigations

• UA –ve castsUA –ve casts

• ABG on 3lit. O2 PaO2 70 PCO2 30ABG on 3lit. O2 PaO2 70 PCO2 30

PH 7.47 HCO3 23PH 7.47 HCO3 23

• CXR & CT CXR & CT

Hospital CourseHospital Course

• Seen by Chest MedSeen by Chest Med

working Dx working Dx Eosinophilic pneumonia Eosinophilic pneumonia

Churg Strauss Syn Churg Strauss Syn

• Open lung Bx was arranged Open lung Bx was arranged

• Started on Systemic steroids , NebulizersStarted on Systemic steroids , Nebulizers


• Septic work up –veSeptic work up –ve

• Improvement on steroids 1-2 lit. O2 94%Improvement on steroids 1-2 lit. O2 94%

• Open lung Bx & BAL on Dec 20Open lung Bx & BAL on Dec 20 thth

Chronic Eosinophilic PneumoniaChronic Eosinophilic Pneumonia

• ANCA both P & C –veANCA both P & C –ve


• WBC 14-16 Neut 85% Initially for 2 daysWBC 14-16 Neut 85% Initially for 2 days

• Gradual worsening SOB & hypoxemia Gradual worsening SOB & hypoxemia Dec23-25thDec23-25th

• Simultaneous recurrence of eosinophilia Simultaneous recurrence of eosinophilia WBC 18 Eosinophil 80%WBC 18 Eosinophil 80%

• Progressive hypoxemia Progressive hypoxemia ICU Dec26th ICU Dec26th


• Mechanical VentilationMechanical Ventilation

• EchoEcho poor window poor window

• Swan Swan No evidence of Lt HF No evidence of Lt HF

• Bronchoscopy Dec 31stBronchoscopy Dec 31st -ve -ve

Hospital CourseHospital Course• Persistent eosinophiliaPersistent eosinophilia

• Cyclophospamide 5 days Cyclophospamide 5 days

• Extubated but didn’t do well High FIO2Extubated but didn’t do well High FIO2

• Didn’t want reintubationDidn’t want reintubation

• Trial BiPAPTrial BiPAP


• EET CS EET CS stenotrophomonas stenotrophomonas Treated with Cipro & CeftazTreated with Cipro & Ceftaz

• Septra was added empirically Septra was added empirically

• Kept worsening with decreased LOCKept worsening with decreased LOC

• Still on BiPAPStill on BiPAP

Hospital CourseHospital Course• A fib A fib Amiodarine Amiodarine

• WBC 23 Eosinophils 65%WBC 23 Eosinophils 65%

• Family meeting Direction of care Family meeting Direction of care PalliativePalliative

• Patient died Jan 9thPatient died Jan 9th


• Causes of Pulmonary eosinophiliaCauses of Pulmonary eosinophilia

• Chronic eosinophilic pneumonia CEPChronic eosinophilic pneumonia CEP Presentation , Dx , Rx , prognosisPresentation , Dx , Rx , prognosis

• Association between CEP & asthmaAssociation between CEP & asthma

• Acute Eosinophilic PneumoniaAcute Eosinophilic Pneumonia

Pulmonary EosinophiliaPulmonary Eosinophilia• Lung infiltrates with peripheral , BALLung infiltrates with peripheral , BAL or tissue eosinophiliaor tissue eosinophilia• Heterogenous group of diseasesHeterogenous group of diseases• Infections Infections Helmenthic Vs Non HelminthicHelmenthic Vs Non Helminthic Helminthic infectionsHelminthic infections different presentations depending of duration different presentations depending of duration

of contact with lung parynchema of contact with lung parynchema & host immune response & host immune response

Helminthic InfectionsHelminthic Infections • Loffler’s Syndrome Loffler’s Syndrome Transpulmonary passage of migrating larvaeTranspulmonary passage of migrating larvae Ascaris , Hookworm & StrongyloidesAscaris , Hookworm & StrongyloidesParasitemiaParasitemia larvae penetrate alveoli & larvae penetrate alveoli & ascends the airways to reach GI ascends the airways to reach GI Dry irritating cough & substernal painDry irritating cough & substernal painFever, SOB & Wheeze +/- hemoptysisFever, SOB & Wheeze +/- hemoptysisMigratory infiltrates with eosinophiliaMigratory infiltrates with eosinophilia

Helminthic InfectionsHelminthic Infections• Direct parynchemal invasionDirect parynchemal invasion Associated with initial eosinophiliaAssociated with initial eosinophilia Echinococcosis,Cysticercosis &Pargonimos Echinococcosis,Cysticercosis &Pargonimos • Visceral larva migransVisceral larva migrans invasion of lung parynchema which is not invasion of lung parynchema which is not

essential in the life cycle of the wormessential in the life cycle of the worm• Tropical EosinophiliaTropical Eosinophilia immune response to blood & lymphatic immune response to blood & lymphatic

stages of the worm Wuchereria bancrofti stages of the worm Wuchereria bancrofti & Brugia malayi & Brugia malayi

Pulmonary EosinophiliaPulmonary Eosinophilia• Non helminthic infectionNon helminthic infection : TB & Cocci : TB & Cocci • Drug reaction Drug reaction NSAIDNSAID Abx (penicillin , Nitrofu, Penatmidine)Abx (penicillin , Nitrofu, Penatmidine) Phenytoin , Ranitidien , GM GCSFPhenytoin , Ranitidien , GM GCSF• Toxins Toxins Inhaled heroin , cocaine or scotchguardInhaled heroin , cocaine or scotchguard rubber & sulfiterubber & sulfite Dust & smokesDust & smokes

Pulmonary EosinophiliaPulmonary Eosinophilia

• ABPA ABPA asthma , central bronchiectasis asthma , central bronchiectasis

• MalignancyMalignancy 1ry lung or 2ry 1ry lung or 2ry

• IdiopathicIdiopathic Hypereosinophilic syndrome Hypereosinophilic syndrome tissue infilitration without obvious causetissue infilitration without obvious cause

• Churg Straus SyndromeChurg Straus Syndrome

• Acute eosinophilic Pneumonia Acute eosinophilic Pneumonia

• Chronic eosinophilic pneumoniaChronic eosinophilic pneumonia


• First described by Carrington 1969First described by Carrington 1969

9 females with background of asthma 9 females with background of asthma & other atopic diseases & other atopic diseases

Worsening SOB ,bilateral lung infiltrates Worsening SOB ,bilateral lung infiltrates

Eeosinophilia peripheral or BALEeosinophilia peripheral or BAL

Dramatic reponse to steroid withDramatic reponse to steroid with recurrence after tapering steroids recurrence after tapering steroids

Chronic Eosinophilic PneumoniaChronic Eosinophilic Pneumonia• Retrospective study 62 patientsRetrospective study 62 patients

• GERM”O”P registeryGERM”O”P registery

French collaborative group French collaborative group

Rare(Orphan)Pulmonary disease 700 Pt 1997Rare(Orphan)Pulmonary disease 700 Pt 1997 Medicine (Baltimore) Sept98Medicine (Baltimore) Sept98


• Inclusion Inclusion

1) Predominantly Peripheral infiltrates1) Predominantly Peripheral infiltrates

2) Blood eosinophilia >or= 1 g/l 2) Blood eosinophilia >or= 1 g/l

or eosin >40% of BALor eosin >40% of BAL

3) Symptoms >2 weekslung 3) Symptoms >2 weekslung

Open lung Bx was not requiredOpen lung Bx was not required


• 77 patients initially 77 patients initially

• 15 excluded: 15 excluded:

3 didn’t meet inclusion 2 exposure to drugs 3 didn’t meet inclusion 2 exposure to drugs

4 insufficient data4 insufficient data

3 +ve serology to helminthes , Asperg.3 +ve serology to helminthes , Asperg.

3 other Dx 3 other Dx malignancy ,sarcoidosis malignancy ,sarcoidosis

Churg Strauss SyndChurg Strauss Synd


• 42 females & 20 males Mean age 45y 42 females & 20 males Mean age 45y

• 6.5% smokers6.5% smokers

• 63% atopic 63% atopic asthma, rhinitis, conjuctivitis asthma, rhinitis, conjuctivitis

dermatitis or drug reactiondermatitis or drug reaction

• Preceding Asthma duration 10 yearsPreceding Asthma duration 10 years


• Mean time from symptoms & Dx 20-65 WMean time from symptoms & Dx 20-65 W

• No patient required mechanical ventilationNo patient required mechanical ventilation

• Hemoptysis was not major symptomHemoptysis was not major symptom

• 9.7% extrapulmonary involvement 9.7% extrapulmonary involvement

arthritis ,skin rash , arthritis ,skin rash ,

pericarditis & hepatitispericarditis & hepatitis


• CXR :CXR : Bilateral 75.8% Bilateral 75.8% Upper lobes 46.8% Vs Lower lobes 11.3% Upper lobes 46.8% Vs Lower lobes 11.3% Upper & Lower 41.9%Upper & Lower 41.9% Migratory opacities 25.5% Migratory opacities 25.5% Small pleural effusion 6.5%Small pleural effusion 6.5% Bilateral hilar LN 1 case. Bilateral hilar LN 1 case.


• CT CT was available for 40 ptwas available for 40 pt

Ground glass & dense infiltrates 72.5%Ground glass & dense infiltrates 72.5%

1Pt small effusion 1Pt small effusion

2Pt with LN 1 hilar & 1 mediastinal 2Pt with LN 1 hilar & 1 mediastinal


• 95% Pt eosinophilia >1 g/l Mean 5.595% Pt eosinophilia >1 g/l Mean 5.5

• 5%Pt eosinophilia < 1 with 40% BAL5%Pt eosinophilia < 1 with 40% BAL

• 4.4% ANA +ve4.4% ANA +ve

• 1 patient +ve PANCA1 patient +ve PANCA

no evidence of other organ involvement no evidence of other organ involvement


• PFT:PFT: was available in 50 pt was available in 50 pt

36% obstructive Vs 32% restrictive 36% obstructive Vs 32% restrictive

?element of airway disease ?element of airway disease

In 20% pt without prior Dx of asthmaIn 20% pt without prior Dx of asthma

Obstructive pattern was found Obstructive pattern was found

• ABGABG : was available in 44 pt : was available in 44 pt

65% hypoxemia <10 Kpa65% hypoxemia <10 Kpa

Chronic Eosinophilic PneumoniaChronic Eosinophilic Pneumonia• Open Lung bxOpen Lung bx6.5% open lung Bx 6.5% open lung Bx

All open Bx All open Bx interstitial infiltrate interstitial infiltrate

& alveolar exudate of eosinophils& alveolar exudate of eosinophils

2 open Bx 2 open Bx additional finding of BOOP additional finding of BOOP


• Transbronchial BxTransbronchial Bx12.5 % transbronchial Bx12.5 % transbronchial Bx

5/8 transbronch Bx 5/8 transbronch Bx interstitial & alveolar interstitial & alveolar infiltrates with eosinophilis infiltrates with eosinophilis 2/5 no abnormality2/5 no abnormality

1/5 organizing pneumonia 1/5 organizing pneumonia (Bx was 2 after systemic steroid) (Bx was 2 after systemic steroid)

Chronic Eosinophilic PneumoniaChronic Eosinophilic Pneumonia• Bronchial Bx :Bronchial Bx : eosinophilic infiltrate in 3 pteosinophilic infiltrate in 3 pt Non had prior AsthmaNon had prior Asthma One developed asthma laterOne developed asthma later

• LN BxLN Bx hyperplasia & esniophilic infiltratehyperplasia & esniophilic infiltrate

• Liver Bx Liver Bx regenerative hepatitis with eosin. regenerative hepatitis with eosin.

Chronic Eosinophilic PneumoniaChronic Eosinophilic Pneumonia• Treatment Treatment : : All except one received systemic steroidsAll except one received systemic steroidsMean dose 1 mg/kgMean dose 1 mg/kg

Rapid clinical improvement 48 hours 82% Rapid clinical improvement 48 hours 82% including extrapulmonary involvementincluding extrapulmonary involvement

Radiological improvement 70% within weekRadiological improvement 70% within week

Variable steroid taperingVariable steroid tapering

Chronic Eosinophilic PneumoniaChronic Eosinophilic Pneumonia• RelapseRelapse48 patients had relapse 12/48 recurrent 48 patients had relapse 12/48 recurrent

28/48 after being off steroid for 55week28/48 after being off steroid for 55week? Rapid taper may be harmless ? Rapid taper may be harmless 20/48 while on tapering dose 10 mg/day20/48 while on tapering dose 10 mg/day

Realapse at different radiological locationsRealapse at different radiological locations

Relapse responded well to steroidRelapse responded well to steroid


• Follow upFollow up46 pt had follow up >1 y Mean follow up 6y 46 pt had follow up >1 y Mean follow up 6y

16 pt had asthma 4/16 were diagnosed after CEP Dx16 pt had asthma 4/16 were diagnosed after CEP Dx

9 pt fixed obstructive PFT 9 pt fixed obstructive PFT

both groups were maitained on systemic steroidboth groups were maitained on systemic steroid

4 died 4 died non respiratory related non respiratory related

CEP & BACEP & BA• Retrospective studyRetrospective study

• Same registry GERM”O”P 1435 pt 2002Same registry GERM”O”P 1435 pt 2002

• Will presence of BA at CEP Dx will affect Will presence of BA at CEP Dx will affect

presentation or outcome ?presentation or outcome ?

• Assess severity & evolution of BA since CEP Dx Assess severity & evolution of BA since CEP Dx

Euro Resp Jr 2003 Vol 22Euro Resp Jr 2003 Vol 22

CEP & BACEP & BA• 53 pt 34 females & 19 male Mean age 4353 pt 34 females & 19 male Mean age 43

• 27 BA +ve prior & 26 BA -ve 27 BA +ve prior & 26 BA -ve

• 34 BA+ve atVs 7 BA+ve after CEP Vs BA -ve 34 BA+ve atVs 7 BA+ve after CEP Vs BA -ve

• 42 Pt follow up>1y 25 BA +ve & 17 BA-ve42 Pt follow up>1y 25 BA +ve & 17 BA-ve

CEP & BACEP & BA

• Higher IgE in asthmaticsHigher IgE in asthmatics

• Tendency to lower BAL eosin. in asthmaticsTendency to lower BAL eosin. in asthmatics

• Tendency to lower eosin. in InhaledTendency to lower eosin. in Inhaled steroid gpsteroid gp

CEP & BACEP & BA• 26/53 BA prior to CEP Dx 76-92 months26/53 BA prior to CEP Dx 76-92 months

• 9 pt mild Vs 12 pt moderate Vs 4 pt severe 9 pt mild Vs 12 pt moderate Vs 4 pt severe

• 60% asthmatics required systemic steroid for 60% asthmatics required systemic steroid for an exacerbationan exacerbation

CEP & BACEP & BA• 42/53 pt Long term follow up 42/53 pt Long term follow up

• Mean FU 87+/-62 monthsMean FU 87+/-62 months

• At last FU At last FU

65% Pt on inhaled steroid for BA65% Pt on inhaled steroid for BA

& 56% on systemic steroid for excacerbation& 56% on systemic steroid for excacerbation

CEP & BACEP & BA

• Asthmatics & inhaled steroid had lower rate of relapseAsthmatics & inhaled steroid had lower rate of relapse ? Inhaled steroids effect? Inhaled steroids effect

• Asthma severity increased after CEP DxAsthma severity increased after CEP Dx ? Equal F:M ratio? Equal F:M ratio & higher smoker in non asthmatics & higher smoker in non asthmatics

• No significant difference in relapse between pt maintained on No significant difference in relapse between pt maintained on or weaned off systemic steroid at last FU or weaned off systemic steroid at last FU

Acute Eosinophilic PneumoniaAcute Eosinophilic Pneumonia

• Retrospective studyRetrospective study

• 22 Pt GERM”O”P22 Pt GERM”O”P

• Inclusion : acute disease <1 monthInclusion : acute disease <1 month

Bilteral lung infiltrtatesBilteral lung infiltrtates

hypoxemia PAO2 <60 or PAO2/FIO2<300hypoxemia PAO2 <60 or PAO2/FIO2<300

lung eosinophilia >25% BAL or Bx lung eosinophilia >25% BAL or Bx

Absence of etiologyAbsence of etiology

• Non had open lung BxNon had open lung Bx

Am Jr Resp & crit care july2002Am Jr Resp & crit care july2002

AEPAEP• 12 met ARDS & 8 met ALI12 met ARDS & 8 met ALI

• All pt had recovered All pt had recovered

? Single organ dysfunction? Single organ dysfunction

• 16/22 were treated with steroid16/22 were treated with steroid

? Use of steroid response as diagnostic criteria ? Use of steroid response as diagnostic criteria

AEPAEP

• FU 12-18 monthsFU 12-18 months

• PFT N at FUPFT N at FU

• Pt who didn’t received steroid normalize CXR Pt who didn’t received steroid normalize CXR earlierearlier

AEP Vs CEPAEP Vs CEP

• Lack of BA Lack of BA • Male predominance Male predominance • Higher percentage of smokersHigher percentage of smokers• Diffuse infiltrate rather than peripheral Diffuse infiltrate rather than peripheral • More effusionsMore effusions• Bx DADBx DAD• Higher number requiring mechanical Higher number requiring mechanical

ventilationventilation• No relapseNo relapse

Thank YouThank You

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Eosinophilic Penumonia