INTRODUCTION: Use of in vitro fertilization (IVF) has increased in recent years. Treatment with intramuscular (IM) progesterone in IVF is standard due to its relative safety and high success rates. We report a case of acute eosinophilic pneumonia (AEP) secondary to IM progesterone.
CASE PRESENTATION: A 27 year old female nonsmoker who was six weeks pregnant with twins after IVF presented with three days of fever, chills, progressive dyspnea and cough. The patient denied exposures to birds, molds or sick contacts. She had recently traveled to India. Her only medications were perinatal vitamins and once daily IM progesterone. Upon admission, the patient was febrile to 100.2°F with a respiratory rate of 30 and an oxygen saturation of 88% on room air. Labs were notable for a leukocytosis of 14,700 and an absolute eosinophil count of 900. Computed tomography of the chest revealed bilateral patchy peripheral opacities and pleural effusions. She was admitted to the ICU and given supplemental oxygen and antibiotics for community acquired pneumonia. Despite mild improvement in her dyspnea, labs showed persistent leukocytosis and eosinophilia. She underwent a bronchoscopy. Bronchoalveolar lavage (BAL) demonstrated 70% eosinophils without organisms on cytology. Bacterial, fungal and AFB cultures were negative, as were stool ova and parasites. Antibiotics were discontinued and progesterone treatments were changed to vaginal suppositories. She was discharged on hospital day four with normal oxygen saturation, no dyspnea and significant improvement on chest x-ray.
DISCUSSION: AEP is an uncommon disease characterized by an acute febrile illness, cough, dyspnea and pulmonary infiltrates which can progress to hypoxemic respiratory failure. Although its etiology is unknown, it has been suggested that AEP may be a hypersensitivity reaction to various inhaled antigens. The diagnosis is confirmed by presence of eosinophilia (>25%) on BAL and exclusion of infectious and systemic causes of pulmonary eosinophilia. Treatment of AEP includes elimination of the suspected underlying cause and systemic corticosteroids. Observational studies show rapid clinical improvement with corticosteroids. Success of IVF depends in part on the maintenance of the luteal phase with progesterone. IM and vaginal progesterone have both been used and there is no definite consensus regarding the optimal route of administration. The IM preparation is dissolved in sesame oil with a benzyl alcohol preservative. We believe that our patient had AEP secondary to IM progesterone. The etiology has been proposed to be a hypersensitivity reaction to the sesame oil or the benzyl alcohol. Compared to similar reports in the literature, a unique aspect of this case is the patient's rapid clinical improvement after discontinuation of the drug without initiation of corticosteroids.
CONCLUSIONS: We present the sixth published case of acute eosinophilic pneumonia caused by IM progesterone injections after in vitro fertilization. We believe that this may be an underreported complication. Our patient's rapid clinical improvement without corticosteroids suggests that close observation after discontinuation of IM progesterone is a feasible option in patients who are not severely ill. It is important for physicians and patients who use IM progesterone to be aware of this serious side effect.
Reference #1 Khan A, Jariwala S, Lieman HJ, Klapper P. Acute eosinophilic pneumonia with intramuscular progesterone after in vitro fertilization. Fertility and Sterility 2008; 90: e3-e6.
Reference #2 Jantz MA, Sahn SA. Corticosteroids in acute respiratory failure. Am J Respir Crit Care Med 1999; 160: 1079-100.
DISCLOSURE: The following authors have nothing to disclose: Cyrus Shariat, Derrick Raptis, Audrey Pendleton, Michael Fingerhood, Ronald Goldenberg
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