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Diffuse Lung Disease |

Chronic Eosinophilic Pneumonia With Prominent Mediastinal Lymphadenopath: Worth a Biopsy?

Nagendra Madisi, MBBS; Neal Chaisson, MD; Ko-Pen Wang, MD
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Department of Internal Medicine, Johns Hopkins University/Sinai Hospital, Baltimore, MD


Chest. 2013;144(4_MeetingAbstracts):450A. doi:10.1378/chest.1704949
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Abstract

SESSION TITLE: Interstitial Lung Disease Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Chronic Eosinophilic Pneumonia (CEP) is a disease of idiopathic origin, characterized by progressive dyspnea, cough, fever, fatigue, and weight loss. Classically, peripheral opacities in the bilateral mid and lower lung fields are apparent, appearing as a “photographic negative” of pulmonary edema(1). No clearly established criteria for CEP exists, but clinical diagnosis is generally made on the basis of a suggestive clinical and radiographic picture, peripheral eosinophilia >6%, and >25% eosinophils in bronchoalveolar lavage(BAL). Prominent mediastinal adenopathy in this setting is rare and can raise the possibility of an alternative diagnosis(2). We present 2 patients with clinical features of prominent mediastinal adenopathy in the setting of CEP.

CASE PRESENTATION: Two previously healthy, non-smoker patients presented to Johns Hopkins Hospital with 1 and 3 months respectively of progressive dyspnea and fatigue. Neither patient reported fever, cough or weight loss. Initial evaluation in both patients demonstrated marked peripheral eosinophilia. CT scan showed patchy ground glass opacities in the bilateral lower lobes. Although CEP was suspected, both patients had significant mediastinal lymphadenopathy, with the largest node in each patient measuring 1.6 x 2.3cm and 2.4 x 4.5cm respectively. Both patients underwent bronchoscopy with BAL and fine needle aspiration (FNA) of mediastinal lymph nodes. In both patients, the cell count on BAL demonstrated ≥30% eosinophils. FNA of mediastinal lymph nodes in one of the patients showed rare eosinophils while the other patient had normal lymphoid tissue with no evidence of eosinophilia. Neither biopsy revealed granuloma or malignancy. Both patients were treated with oral corticosteroids with rapidly improved symptoms and complete resolution of peripheral eosinophilia. Repeat CT scan following therapy demonstrated decreased lymphadenopathy and infiltrates.

DISCUSSION: Mediastinal lymph nodes >1 centimeter in diameter are generally considered pathologic and can represent both benign and malignant etiologies. Due to the rare occurrence of lymphadenopathy in CEP, FNA biopsy was performed in both patients presented here. FNA did not improve our ability to make a diagnosis in either case. Lymph node burden also decreased significantly with therapy in both cases.

CONCLUSIONS: Although lymph node biopsy is indicated in many patients with prominent mediastinal adenopathy, when CEP is otherwise suspected, BAL alone, followed by repeat CT after completion of therapy may provide an alternative approach to lymph node biopsy. Larger studies are necessary to confirm these findings.

Reference #1: Marchand E et al. Idiopathic Chronic Eosinophilic Pneumonia; A Clinical and Follow up Study of 62 Cases. 1998. Medicine; 77(5); 299-312.

Reference #2: Nihon Kyobu Shikkan Gakkai Zasshi. 1997 Apr;35(4):447-50. Bilateral hilar and mediastinal lymphadenopathy accompanying pulmonary infiltration with eosinophilia

DISCLOSURE: The following authors have nothing to disclose: Nagendra Madisi, Neal Chaisson, Ko-Pen Wang

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