A 40 year old woman with malaise, night sweats, and pulmonary infiltrates. She had had two separate courses of antibiotics (azithromycin and levofloxacin) with no benefit. She had malaise, occasional sweats, a non-productive cough, and nasal obstruction. There was also a central soreness across her chest.
Past history included upper airway allergy symptoms requiring occasional courses of anti-histamines, and an intermittent cough but no clear-cut history consistent with asthma. She also had depression requiring fluoxetine (prozac).
Physical examination was normal apart from slight pallor. There were no crackles or wheezes. There was no hepatomegaly.
Laboratory investigations showed a slight anemia (Hgb 10g/dl), an elevated ESR (118 mm/min), a white cell count of 10,000/L , with an absolute eosinophil count of 0.9 x 109/L. P-ANCA and ANA were weakly positive, C-ANCA, and RF were negative. Serum IgE was normal. Urinalysis was clear.
Radiographs are as shown. Dense infiltrates are visible both on the plain radiograph (postero-anterior view, and lateral view), primarily posteriorly in the upper lobes, which is confirmed on the CT scan as shown.
A diagnostic procedure was performed.
A bronchoscopy was performed with a broncho-alveolar lavage. The differential on the nucleated cells (total count 201/mm3) showed that 50% were eosinophils, 20% were lymphocytes. The fluid was negative for all infectious agents.
A diagnosis of chronic eosinophilic pneumonia was made, and the patient started on 60 mg prednisone. A rapid recovery was noted, both clinically and radiographically.
Chronic eosinophilic pneumonia:
First described in the 1960s by Carrington et al, this condition occurs in predominantly middle aged females, classically with a history as above: vague symptoms lasting several weeks, with no resolution with antibiotics, typically with peripheral infiltrates on the chest radiograph (1). Typically there are few physical findings, though wheezes may be present, and mild hepatomegaly. There is often an antecedent history of asthma or nasal allergy, though not invariably. Often there is a mild peripheral eosinophilia, with a striking eosinophilia in bronchoscopic lavage specimens. The IgE is often normal. There is a rapid recovery on steroids at high dose, but the risk of relapse is fairly high, and often treatment has to be continued at low dose for several months to years (2). The condition should be distinguished from Acute Eosinophilic Pneumonia, a condition characterized by an acute onset of respiratory failure, often requiring intubation and mechanical ventilation, a rapid response to steroids, with little chance of relapse (3). There is usually no antecedent history of asthma or allergy.
References
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