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Extreme Peripheral Eosinophilia in a Patient With a Skin Rash and Abnormal Chest Imaging FREE TO VIEW

Bashar Farjo*, MD; George Nassif, MD
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University of Texas, Health Science Center, Houston, TX

Chest. 2012;142(4_MeetingAbstracts):983A. doi:10.1378/chest.1389581
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SESSION TYPE: Miscellaneous Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: A unique case of lung disease and extreme eosinophilia.

CASE PRESENTATION: A 56-year-old Caucasian male with epilepsy and 3 months history of asthma is hospitalized for skin purpura and arthralgia. He had cough, dyspnea on exertion, fever with significant constitutional symptoms. His medications are lamotrigine, montelukast and inhaled bronchodilators. Physical examination positive for fever, bilateral nasal turbinate hypertrophy, bilateral pitting ankle edema, and palpable purpura of the legs. Laboratory studies show leukocytosis with extreme eosinophilia (70%, absolute eosinophil count (AEC) of 21.2 k/cmm). He developed acute oliguric renal failure. Urinalysis positive for proteinuria and hematuria. Rheumatogical work up showed negative C-ANCA, P-ANCA (antineutrophil cytoplasmic autoantibody), viral hepatitis panel, and normal C3/C4 complement levels. Chest computerized tomography (CT) showed bilateral pulmonary ground-glass opacities (GGO). Renal core needle biopsy revealed pauci-immune crescentic glomerulonephritis with fibrinoid necrosis and acute eosinophilic interstitial nephritis. Skin biopsy had vasculitis with eosinophilic inflammatory cell infiltrate. The clinical picture was suggestive of Churg-Strauss Syndrome. He was given pulse steroid therapy with methylprednisolone and intravenous cyclophosphamide. The peripheral eosinophil count reduced to 3% (600k/cmm) within 31 hours. He was discharged on maintenance regimen. Repeat chest CT showed complete resolution of the bilateral GGO three month later. The patient has experienced clinical remission for 1.5 years now.

DISCUSSION: The presence of asthma, eosinophilia, pulmonary infiltrates, vasculitis strongly suggested the diagnosis of Churg-Strauss Syndrome. In literature review, mean AEC in Churg-Strauss Syndrome was 7.1, highest reported as 44k/cmm). Other etiologies for GGO with eosinophilia include: A) Tropical filarial pulmonary eosinophilia (mean 15.6, highest reported 80 k/cmm), B) Idiopathic hypereosinophilic syndrome (AEC mean 6.6 K/cmm, highest reported 400 k/cmm), C) idiopathic chronic eosinophilic pneumonia (AEC mean 5.5K/cmm, highest reported 37.8 k/cmm, D) allergic bronchopulmonary aspergillosis(mean AEC 0.8 , highest reported 14.1 k/cmm) Careful clinical and pathological correlation is necessary to establish the correct diagnosis

CONCLUSIONS: This patient’s eosinophilia (70%) is extreme but not unforeseen for Churg- Strauss syndrome.

1) Guillevin L, et al. Churg-Strauss syndrome. Clinical study and long-term follow-up of 96 patients. Medicine (Baltimore. 1999 Jan;78(1):26-37.

2) Ogbogu PU, et al. Hypereosinophilic syndrome: a multicenter, retrospective analysis of clinical characteristics and response to therapy. J Allergy Clin Immunol. 2009 Dec;124(6)

3) Marchand E, et al. Idiopathic chronic eosinophilic pneumonia. A clinical and follow-up study of 62 cases.. Medicine (Baltimore). 1998 Sep;77(5):299-312.

DISCLOSURE: The following authors have nothing to disclose: Bashar Farjo, George Nassif

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University of Texas, Health Science Center, Houston, TX




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