Eosinophils at Work: Cavitary Lung Lesions in a Young Nurse
Mishra K, Sharma S, Gorgis S, and Zervos M. Eosinophils at Work: Cavitary Lung Lesions in a Young Nurse. J Gen Intern Med 2019; 34(2):S526-S527.
J Gen Intern Med
Learning Objective #1: Develop a differential diagnosis for cavitary lung lesions Learning Objective #2: Diagnose and treat chronic eosinophilic pneumonia CASE: A 35 year-old woman with recurrent sinusitis and development of asthma-like symptoms presented with two months of progressively worsening shortness of breath, wheezing and productive cough. She is an avid runner and noticed a significant decrease in her exercise capacity. She works as a CRNA in the bronchoscopy suite and her last PPD six months ago was negative. Vital signs were stable. Physical examination revealed bilateral wheezes. She had a leukocytosis of 13.3 K/uL with eosinophilia (absolute eosinophils 2.30 K/uL). Computed tomography (CT) thorax revealed pulmonary nodular densities with cavitations. A workup for infectious (tuberculosis, aspergillus, histoplasma, blastomycosis, coccidioides), vasculitis (p-ANCA, c-ANCA), and autoimmune (ANA, dsDNA, Anti-Smith, Anti-RNP) disease was negative. Pulmonary function tests (PFTs) showed FEV1 of 103% with FEV1/FVC ratio of 73%. The patient made symptomatic improvement on scheduled bronchodilators. Bronchoscopy revealed normal airways. Biopsy showed alveolar lung tissue with minimal inflammatory infiltrate, clusters of pigment-laden macrophages and minimally thickened alveolar septa. Bronchoalveolar lavage (BAL) was positive for 49% eosinophils and negative for infection. She was diagnosed with chronic eosinophilic pneumonia (CEP). The patient received inhaled corticosteroids and short acting beta agonists with symptomatic improvement. Repeat PFTs two weeks later showed improvement. CT thorax after 3 months showed improved ground glass opacities with stable pulmonary nodules. The patient endorsed complete resolution of symptoms at follow up and returned to her normal exercise capacity. IMPACT/DISCUSSION: Chronic eosinophilic pneumonia is a rare disease which accounts for 2.5% of interstitial lung disease. It is an idiopathic disorder described by abnormal accumulation of eosinophils in the inter-stitium and alveolar spaces of the lung. Patients typically have a history of atopy, prolonged asthma-like symptoms, and exercise intolerance. IgE levels, peripheral eosinophilia, and elevation in inflammatory markers are nonspecific, but common. Bronchoalveolar lavage is essential to the diagnosis, as it can rule out infection and reveal alveolar eosinophilia. The BAL eosinophil count is almost always > 25%, with more than 80% of patients having a BAL eosinophil count > 40%. Glucocorticoids are the mainstay of management and patients often require long term systemic steroids. However, our patient made significant symptomatic improvement on inhaled steroids. Conclusion: CEP often presents with nonspecific respiratory symptoms which leads to delays in diagnosis. Early clinical suspicion upon recognition of marked peripheral eosinophilia can lead to timely imaging and procedures (BAL) that are required to make the diagnosis.