25 Eosinophilic Lung Disease
25.1 What this covers
- Simple Pulmonary Eosinphilia (Loeffler’s Syndrome)
- Illness Script
- Who does it occur in?
25.2 Learning objectives
- Simple Pulmonary Eosinphilia (Loeffler’s Syndrome)
- Illness Script
- Who does it occur in?
- How does it present?
- How is it diagnosed?
- Acute Eosinophilic Pneumonia
- How is it treated
25.3 Bottom line / summary
- #Eosinophilic Lung Disease
- Often have a history of atopic disease
- Blood eosinophilia Mild dyspnea, cough Transient / migratory areas of consolidation or ground glass, usually with ill-defined margins.
- Often predominantly peripheral distribution.
- Rapid resolution with steroids
25.4 Approach
- 20-40 years old
- 2:1 male:female ratio.
- Sometimes presents in people after they begin smoking (or vaping)
- Can be caused by daptomycin, venlafaxine
- Acute onset fevers, shortness of breath, hypoxemic respiratory failure
25.5 Red flags / when to escalate
- TODO: List red flags that require urgent escalation.
25.6 Common pitfalls
- TODO: Capture common errors or missed steps.
25.7 References
TODO: Add landmark references or guideline citations.
25.8 Source notes
25.8.1 Eosinophilic Lung Disease
26 Eosinophilic Lung Disease
26.1 Simple Pulmonary Eosinphilia (Loeffler’s Syndrome)
26.1.1 Illness Script
26.1.1.1 Who does it occur in?
Often have a history of atopic disease
26.1.1.2 How does it present?
Blood eosinophilia Mild dyspnea, cough Transient / migratory areas of consolidation or ground glass, usually with ill-defined margins. Often predominantly peripheral distribution. May have nodules
26.1.1.3 How is it diagnosed?
26.2 Acute Eosinophilic Pneumonia
26.2.1 Illness Script:
26.2.1.1 Who does it occur in?
- 20-40 years old
- 2:1 male:female ratio.
- Sometimes presents in people after they begin smoking (or vaping)
- Can be caused by daptomycin, venlafaxine
26.2.1.2 How does it present?
- Acute onset fevers, shortness of breath, hypoxemic respiratory failure
26.2.1.3 How is it diagnosed?
- CXR abnormalities are non-specific, but similar to pulmonary edema (kerley b lines -> interstitial opacity -> air space consolidation, lower lobe predominance and bilateral)
- CT shows bilateral consolidation, interlobular septal thickening, sometimes with associated pleural effusion
- BAL with %eosinphils greather than 25%
26.2.1.4 How is it treated
- responds within days to high dose corticosteroids, Rx’d for 2 weeks.
- start after infectious pneumonia is excluded.
- sometimes remits on its own
- long term prognosis is excellent
26.3 Chronic Eosinophilic Pneumonia
26.3.1 Illness Script:
26.3.1.1 Who gets it?
26.3.1.2 How does it present?
- Fever, cough, weight loss, malaise, dyspnea
- Blood eosinophilia
- Severe symptoms, last 3 months or more
- CT with patchy, peripheral, homogenous air space consolidation (photographic negative of pulmonary edema). Sometimes may have crazy paving. Similar to organizing pneumonia, without the basilar predominance.
- remains unchanged (unlike Loeffler’s) unless steroids given.
26.3.1.3 How is it diagnosed
- Lung biopsy, unless imaging findings are classic.
26.3.1.4 How is it treated
Rapid resolution with steroids
26.4 Hypereosinophilic syndrome
26.4.1 Illness Script
26.4.1.1 Who does it occur in?
26.4.1.2 How does it present
- Elevated blood eos for 6 months, multiorgan infiltration (morbidity from cardiac, cns involvement) -If pulm involvement: cough, wheeze, SOB
- Hazy GGOs, pulmonary nodules 1cm or less in diameter in the peripheries on HRCT.
26.5 Eosinophilic Granulomatosis with Polygangiitis
aka Churg-Strauss; extravascular granulomas and necrotizing vasculitis with eosinophils infiltrating various organs.
26.5.0.1 Who gets it?
- 40-50 years old
- often hx of atopic disease.
26.5.0.2 How does it present?
- Allergic/prodromal phase: rhinitis, sinusitis, asthma
- Eosinophilic phase: Blood eosinophils over 10%, Lung (often resembles Loeffler’s or chronic eosinophilic pneumonia) and GI involvement
- Systemic Vasculitis phase: “Polyangiitis”, heart, skin, MSK, CNS, kidney also involved - fever weight loss, malaise occur.
CXR w/ Transient pulmonary opacities, +/- nodules/masses, hemorrhage, edema, effusion.
HRCT with consolidation/GGOs (60%), bronchial wall thickening or bronchiectasis (35%), septal thickening (5%)
Cavitation is less common than with GPA
26.5.0.3 How do you make the diagnosis
- send ANCAs (usually p-anca)
- eosinophils extravascularly
26.5.0.4 How is it treated
- Usually respond to steroids
26.6 Other eosinophilic lung conditions
- Drug reactions
- Parasite infections (Ascaris, Toxocara, Strongyloides), Tropical pulmonar eosinophilia
- Fungal disease (ABPA)
- Bronchocentric granulomatosis (necrotizing granulomas centered on bronchioles caused by hypersensitivity, upper lobe predominance)