Following the steroid therapy, symptoms of dry intermittent cough, nausea, vomiting, fever, intermittent abdominal pain, epistaxis, and difficulty swallowing developed and progressively worsened. The patient was referred to our institution for consultation. A chest radiograph demonstrated bilateral patchy alveolar infiltrates with peripheral consolidation that expanded over the next 48 h (Fig 1
). Symptoms included a temperature of 38.9°C, shortness of breath, nausea, vomiting, and rigors. Subsequent to hospital admission, his temperature was 38.1°C, pulse rate was 135 beats/min, respiratory rate was 28 breaths/min, and BP was 101/58 mm Hg. Oxygen saturation was 90% on room air, but corrected to 100% on 1 L of oxygen per nasal cannula. The lung examination was notable for bilateral crackles greater on the right side than the left side, and decreased breath sounds on the left. Arterial blood gas was pH 7.44; Pco2, 29 mm Hg; Po2, 109 mm Hg; and HCO3, 19 mEq/L on 1 L of oxygen via nasal cannula. The WBC count was 19.8 × 109/L with 48% eosinophils on differential count, erythrocyte sedimentation rate of 9 mm/h, and lactic dehydrogenase level of 625 U/L. Serum IgE measured 1,780 IU/mL. An antineutrophil cytoplasmic antibody test result was negative, and serologic testing for HIV, aspergillus precipitins, and antibodies to Epstein-Barr virus was negative. B cells, T cells, T-cell subsets, and metabolic panels were normal. Fluid from bronchoscopy with transbronchial biopsy and BAL contained 1.5 × 109/L WBCs with a differential count of 4% neutrophils, 17% mononuclear cells, 79% eosinophils, and numerous lipid-laden macrophages. The transbronchial lung biopsy showed large numbers of alveoli filled with eosinophils, macrophages, and neutrophils in a background of fibrinous material (Fig 2
). Alveolar septa were edematous with patchy eosinophilic infiltration, also found in the bronchiolar area. Interstitial granulation tissue was present focally as well as focal bronchiolar infiltration by eosinophils; however, bronchial changes indicative of asthma were absent. Swollen endothelial cells lined the scattered small blood vessels that contained luminal neutrophils and eosinophils, but fibrinoid necrosis and leukocytoclasis were not observed. A silver methenamine stain was negative for fungi. The biopsy findings were diagnostic of an acute exacerbation of CEP.