Eosinophilic lung diseases encompass a wide variety of pulmonary disorders. We describe a case of eosinophilic lung disease which does not fall into any of the categories that have been previously reported in the literature.
A 43 year old female presented with acute dyspnea, wheezing and chest tightness. She denied cigarette smoking and drug use and had no history of previous illnesses including HIV or tuberculosis. She had never traveled outside of Michigan, she had no pets, and she denied any occupational exposures or toxic inhalation. Exam was remarkable only for bilateral wheezing. Peripheral blood eosinophil count was 1280/mm3. Serum creatinine was normal and there was no hematuria or proteinuria. Serologies for HIV, antinuclear antibody, anti-neutrophil cytoplasmic antibody, and rheumatoid factor were negative. Stool cultures were negative for ova and parasites. Chest X-ray and CT scan both revealed bilateral diffuse micronodules as shown below. Bronchoalveolar lavage excluded infection. Kveim test was negative. Open lung biopsy was performed and histopathology revealed necrotizing granulomas with tissue eosinophilia as shown below.DISCUSSION: The combination of peripheral eosinophilia, tissue eosinophilia, and necrotizing granuloma would be consistent with allergic granulomatosis and angiitis. However, the absence of atopy and lack of vasculitis makes this diagnosis unlikely. The literature describes isolated cases of eosinophilic lung disease secondary to medications, infections, and sarcoidosis, but our patient had an extensive workup including bronchoscopy and Kveim test that excluded these etiologies. Eosinophilia in Wegener’s granulomatosis has been described, but the negative ANCA coupled with the absence of vasculitis makes this diagnosis unlikely.
By excluding previously reported etiologies of eosinophilic lung disease, we conclude that this case may represent a new entity, which we describe as non-allergic granulomatosis with eosinophilia.
U.G. Nayak, None.