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A Case of Eosinophilic Pneumonia Following Recent Onset of Hookah Smoking FREE TO VIEW

Herman Dyal, MD; Aditi Singhvi, MD; Ruchir Patel, MD; Michael Mendez, MD; Krishna Thavarajah, MD; Jeffery Jennings, MD
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Henry Ford Health System, Detroit, MI

Chest. 2014;146(4_MeetingAbstracts):406A. doi:10.1378/chest.1968687
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SESSION TITLE: ILD Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: We report a case of acute eosinophilic pneumonia (AEP) following recent onset of hookah smoking. Various inhalational exposures have been associated with AEP, however to our knowledge, this is the first report of AEP in conjunction with hookah smoking.

CASE PRESENTATION: A 26-year-old Middle Eastern female was admitted with cough, dyspnea, pleuritic chest pain and fever for two days. She had no significant medical history. She denied smoking, toxic exposures or use of illicit drugs. On admission, she was afebrile, tachycardic, normotensive, tachypneic and had normal oxygen saturation on ambient air. She had rhonchi and bibasilar crackles. Erythrocyte sedimentation rate was 47mm/hr. The following tests had normal or negative results: hemoglobin level, white blood cell count and differential, platelet count, levels of anti-neutrophil cytoplasmic antibody and antinuclear antibody, HIV ELISA and legionella serology. Initial chest radiograph was unremarkable. Spiral computed tomography of the chest revealed multiple tiny nodular opacities in the right lower lobe adjacent to peribronchovascular bundles (Fig 1). The patient continued to deteriorate and was also febrile, despite antibiotics. Chest radiograph on day 3 showed bilateral pulmonary opacities (Fig 2). She was hypoxic requiring supplemental oxygen necessitating transfer to the intensive care unit where she admitted to smoking hookah for the past month. Following intubation on day 4, bronchoscopy was performed and bronchoalveolar lavage revealed 261/ mm3 white blood cells with 61% eosinophils. She was diagnosed with AEP. Antibiotics were discontinued and treatment with prednisone was started with good response. She was discharged on a prednisone taper for thirteen weeks.

DISCUSSION: AEP is characterized by acute febrile illness, hypoxemia, diffuse pulmonary infiltrates and pulmonary eosinophilia1. It is hypothesized to be an acute hypersensitivity reaction to an inhaled antigen in an otherwise healthy individual. A number of drugs and toxins have been associated with AEP. Antibiotics and non-steroidal anti-inflammatory drugs are the most commonly reported drugs. Toxins suspected to cause AEP include cigarette smoke, marijuana and cocaine. AEP has also been noted to develop after exposure to smoke from fireworks, dust from collapse of the World Trade Center and in military personnel deployed in Iraq. However, to our knowledge, hookah smoking leading to development of AEP has not been described.

CONCLUSIONS: In patients who present with respiratory failure and pulmonary infiltrates after recent exposure to inhaled toxins, AEP should be considered as a possible diagnosis. As hookah use becomes increasingly prevalent, this will become a more frequently identified cause of AEP.

Reference #1: Allen JN, Pacht ER, Gadek JE, Davis WB. Acute eosinophilic pneumonia as a reversible cause of noninfectious respiratory failure. N Engl J Med 1989; 321:569

DISCLOSURE: The following authors have nothing to disclose: Herman Dyal, Aditi Singhvi, Ruchir Patel, Michael Mendez, Krishna Thavarajah, Jeffery Jennings

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