A Chronic Eosinophilic Pneumonia Case With Pleural Involvement

Abstract

INTRODUCTION: Chronic eosinophilic pneumonia (CEP) is an idiopathic eosinophilic pulmonary disease characterized by an abnormal and marked accumulation of eosinophils in the lung. Common presenting complaints include cough, fever, dyspnea, wheezing, and night sweats. Common laboratory abnormalities are peripheral blood and BAL eosinophilia. We report a rare case of chronic eosinophilic pneumonia with pleural involvement. CASE PRESENTATION: A 28 year-old woman with past medical history of asthma presented to our pulmonary department for evaluation. Patient reported fever, chest pain, cough, productive purulent sputum, these symptoms worsened gradually over 10 days, and she received systemic steroids several times without doctor control in past 6 months. In laboratory analysis WBC: 25.450 K/uL, hgb 16.1 g/dL, hct % 47.7, platelets 560 K/uL, CRP 134 mg/l and sputum culture (-). Computed tomography of the thorax showed bilateral multifocal consolidation area, and pleural involvement. Inhaled bronchodilator therapy, systemic corticosteroids and appropriate antibiotic therapy were started. Symptoms were improved after couple of days on the beginning of therapy, however systemic steroids was stopped on 6th days of therapy due to the severe dyspeptic symptoms. Symptoms were aggravated on the second week of treatment, and radiological findings were also progressive. Antibiotics were changed and upper group antibiotics were given. However, symptoms and radiological findings worsen. We re-evaluated the patient on 20th day of therapy. Laboratory studies showed WBC of 17.650 K/uL, CRP 97.6 mg/l, eosinophils %10.5, procalcitonin 0.09 ng/ml, P-Anca(-), RF: 46,6(+), Total IgE:376 IU/ml, sputum culture: candida colonization, Aspergillus Sp IgE(-), Galactomannan (-), AFB(-) and normal urine analysis. Systemic steroids were started again from 1 mg/kg doses with the diagnosis of Eosinophilic Lung Diseases. Symptoms started to improve on first week of systemic steroids therapy. Radiological findings disappeared after one month therapy. DISCUSSION: The clinical picture of the disease is progressive and severe illness characterized by high fever, weight loss, night sweats, and shortness of breath. Most patients are middle aged and women are more frequently affected than men. Because approximately 50% of the patient has the past history of asthma, Churg-Strauss disease is one of the top differential diagnosis. Symptom is often severe, but life-threatening respiratory dysfunction is not common (1). Our case is a middle aged woman with a history of asthma, and her symptoms worsen in the last 6 months. The radiological profile is highly suggestive of peripheral consolidation that responds promptly to corticosteroids, although it has a high recurrence rate. In our case, radiological findings contain bilateraly peripheral consolidation with pleural involvement which was similar to CEP. However, pleural involvement was also observed differently from typical CEP pneumonia, good steroids response was observed in one month steroid treatment. The most common clinical abnormality is an elevated peripheral blood eosinophil count. Other laboratory abnormalities may include elevated serum IgE and rheumatoid factor (2). Peripheral blood eosinophil count, IgE and rheumatoid factor were significantly high in our patients. It can be secondary to known causes, such as drugs, parasites and irradiation for breast cancer, or be associated with rheumatoid arthritis, as well as having been described after several types of aggression, such as childbirth and desensitization using immunotherapy (allergy shots). Typically, CEP is idiopathic, and this is the most extensively studied form (3). In our case, there is no cause of aggravation, we accepted our patient as a idiopathic CEP. CONCLUSIONS: In conclusion, CEP can occasionally present with an acute onset. This rare and severe disease should be remembered in patients presenting with an acute onset of chest infiltrates and peripheral blood eosinophilia.