SESSION TITLE: Miscellaneous Cases I
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM
INTRODUCTION: Acute eosinophilic pneumonia (AEP) is a rare cause of acute febrile respiratory failure, often requiring mechanical ventilation support for severe hypoxemia. Etiology is often unknown. We report a case of severe rapidly progressing AEP after use of a hookah (water pipe) in which extracorporeal membrane oxygenation (ECMO) was needed to maintain adequate oxygenation until a successful response to corticosteroid treatment was observed.
CASE PRESENTATION: 22-year-old Saudi Arabian male, in the United States for one month, presented with 2 days of fever, cough and progressive shortness of breath. He had smoked a hookah before coming to the U.S., and restarted two days before the onset of symptoms. On examination, patient was using accessory muscles of respiration, respiratory rate: 25-30/min, temperature: 103.2°F, and room air oxygen saturation: 88-90%. Lung exam revealed bilateral crackles. WBC count was 25,000/mm3 with 92.6% neutrophils and 1.7% eosinophils. Chest radiograph showed diffuse infiltrates. Computed tomography revealed bilateral scattered ground glass opacification. Despite broad-spectrum antibiotics and mechanical ventilation with 100% FIO2 and positive end expiratory pressure, infiltrates and oxygenation worsened. Mirobiological cultures, serologies, HIV antibody, and toxicology screen were negative. Bronchoscopy with bronchoalveolar lavage (BAL) demonstrated diffusely inflamed mucosa without evidence of bleeding. Plans were made to transfer the patient for ECMO. Soon after, BAL fluid results became available and revealed an eosinophil count of 78%; stains for microorganisms were negative. Methylprednisolone and ECMO were initiated. The patient rapidly improved and was discharged home after seven days.
DISCUSSION: AEP is characterized by acute febrile respiratory failure, diffuse bilateral infiltrates on chest radiograph, and eosinophilia in BAL fluid, in the absence of infection or alternative causes for eosinophilia. Etiology may be related to an acute hypersensitivity reaction to an inhaled allergen. Early diagnosis and treatment with corticosteroids is essential, since the prognosis is excellent if corticosteroid therapy is instituted promptly. To our knowledge, this is the first case of AEP attributed to smoking a water pipe, and one of only a few reported cases requiring ECMO to manage refractory hypoxemic respiratory failure.
CONCLUSIONS: AEP should be considered in patients with unexplained acute febrile respiratory failure. BAL with differential cell count should be performed early if the etiology is in question. ECMO to maintain adequate oxygenation can be used as a bridge in patients with life threatening hypoxemia while corticosteroid treatment is initiated.
Reference #1: Philit F, Etienne-Mastroianni B, Parrot A, Guerin C, Robert D, et al. Idiopathic acute eosinophilic pneumonia: a study of 22 patients. Am J Respir Crit Care Med. 2002;166:1235-1239.
DISCLOSURE: The following authors have nothing to disclose: Vishal Raj, Andrew Berman
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