Acute eosinophilic lung disease secondary to drug reaction

Case contributed by Dalia Ibrahim

Presentation

Low-grade fever, cough, and dyspnea. History of recent drug uptake (antidepressant drugs) 1 week before the start of the acute chest and skin manifestations.

Patient Data

Age: 20 years
Gender: Male

Bilateral pulmonary peripheral and predominantly lower lobar patches of ground glass attenuation. This is associated with right lower lobar smooth interlobular septal thickening.

Bilateral mildly enlarged axillary lymph nodes.

Scanned upper abdominal cuts showed hepatospelnomegaly.

The presence of pulmonary ground-glass patches, hepatosplenomegaly, and axillary lymph nodes was suggestive of autoimmune disease. The presence of smooth interlobular septal thickening was suggestive of Eosinophilic lung disease.

In view of the clinical data with recent drug uptake and skin eczema, Eosinophilic lung disease secondary to drug reaction is considered.

Note the peripheral distribution of the pulmonary ground glass patches, associated with smooth interlobular thickening.

Clinical photographs of the patient's abdomen and arm showed extensive skin eczema.

A complete blood picture (CBC) revealed: Marked absolute eosinophilia (14.0 %), RBCs mild hypochromia, mild leukocytosis, absolute monocytosis,

Case Discussion

The patient had a history of recent antidepressant drug uptake one week before the start of acute low-grade fever, cough, dyspnea, and extensive widespread skin eczema.

CT scan of the chest revealed bilateral pulmonary mainly peripheral subpleural patches of ground glass attenuation, associated with smooth interlobular thickening, which was suggestive of eosinophilic lung disease.

CBC revealed marked absolute eosinophilia (14%).

Diagnosis of secondary (drug-induced) eosinophilic lung disease was made. The causative drug was stopped immediately and the patient received prednisolone therapy for 1 week after which he had a dramatic clinical improvement.

Eosinophilic lung diseases are a diverse group of pulmonary disorders associated with peripheral or tissue eosinophilia.

They are divided into three main groups

  • idiopathic: unknown causes (simple pulmonary eosinophilia, acute eosinophilic pneumonia, chronic eosinophilic pneumonia, idiopathic hypereosinophilic syndrome)
  • secondary: known causes (drugs, parasites, allergic bronchopulmonary aspergillosis, bronchocenteric granulomatosis)
  • eosinophilic vasculitis: eosinophilic granulomatosis with polyangiitis(Churg-Strauss syndrome)

Diagnosis is made based on one of the following:

CT demonstrates a more characteristic pattern and distribution of parenchymal opacities as follows

  • Simple pulmonary eosinophilia (SPE): transient areas of air-space consolidation which usually resolve spontaneously within 1 month. These consolidations are usually peripheral, may be single or multiple, and usually have ill-defined margins. Sometimes it might appear as airspace nodules with surrounding ground-glass opacity
  • Acute eosinophilic pneumonia (AEP): bilateral patchy of ground-glass opacities, usually associated with interlobular septal thickening, sometimes consolidations or poorly defined nodules
  • Chronic eosinophilic pneumonia (CEP): peripheral airspace consolidations with peripheral predominance, might be associated with ground glass opacities, nodules, or reticulations
  • Idiopathic hypereosinophilic syndrome: pulmonary involvement is often non-specific and consists of focal or diffuse, interstitial or alveolar non-lobar opacities
  • Allergic bronchopulmonary aspergillosis:  mucoid impaction and bronchiectasis involving predominantly the segmental and subsegmental bronchi of the upper lobes giving the gloved finger appearance
  • Parasitic infections: consolidations, nodules, bronchiectasis
  • Drug reactions: Patients with drug-induced eosinophilic lung disease can present with a variety of pathologic conditions ranging from a mild, SPE-like syndrome to a fulminant, AEP-like syndrome, airspace consolidations and ground glass opacities in a peripheral distribution
  • Eosinophilic vasculitis (Churg-Strauss syndrome): The diagnosis of Churg-Strauss syndrome can be made if four or more of the following six findings are present: asthma, eosinophilia >10%, neuropathy, transient pulmonary opacities, paranasal sinus abnormalities, and extravascular eosinophils revealed at biopsy. CT findings include subpleural ground-glass opacities or consolidations with a lobular distribution, centrilobular nodules, bronchial wall thickening, and interlobular septal thickening

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