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Thinking Outside the Box: Acute Hypoxic Respiratory Failure in a 56 Year Old Female FREE TO VIEW

Michael Megally, MD; Aveena Kochar, MD; Jordan Taillon, MD; George Juan, MD; Anu Thomas, MD; Jeremy Weingarten, MD
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New York Methodist Hospital, Brooklyn, NY

Chest. 2015;148(4_MeetingAbstracts):405A. doi:10.1378/chest.2281038
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SESSION TITLE: Diffuse Lung Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Acute eosinophilic pneumonia (AEP) is an uncommon cause of acute hypoxemic respiratory failure resulting from eosinophilic infiltration of the lung parenchyma. We present a case that was initially treated as acute respiratory distress syndrome (ARDS) secondary to multifocal pneumonia and subsequently found to be AEP.

CASE PRESENTATION: A 56 year old woman with a history of Stage IVB Mycosis Fungoides T-Cell Lymphoma diagnosed in 1981 being treated with EPOCH chemotherapy, on dapsone for prophylaxis, and clindamycin and rifampin for axillary abscess presented with productive cough, tachypnea, and pleuritic pain for one day. Imaging revealed diffuse patchy opacifications. Upon endotracheal intubation, she had cardiac arrest with return of spontaneous circulation after 9 minutes of resuscitative efforts. She required vasopressors for continued hypotension, antibiotics were initiated for pneumonia, and high dose steroids were started for possible AEP. 36 hours post intubation, a bronchoscopy with BAL revealed 18% eosinophils, negative cultures, and negative cytology. Without a likely infectious source, antibiotics were discontinued. Following high dose steroids she clinically and radiologically improved and was extubated and discharged home. Based on results of the BAL, hospital course, and meeting all other diagnostic criteria, AEP was the final diagnosis.

DISCUSSION: AEP results from eosinophilic infiltration of the lung parenchyma, and is thought to be caused by inhaled antigens and seen in people with changed smoking habits. AEP presents in ages 20-40, with a slight male predominance. Symptoms include dry cough, dyspnea, fever, pleuritic pain, and rapid progression to respiratory failure requiring mechanical ventilation in 63%. Exam demonstrates tachypnea with bibasilar crackles and occasional rhonchi; normal lung exam is present in a minority of cases. Labs usually show leukocytosis with or without peripheral eosinophilia. Imaging reveals subtle opacities with Kerley-B lines which rapidly evolve to diffuse parenchymal opacities. 70% present with eosinophilic exudative pleural effusions. Diagnostic Criteria for AEP are: febrile illness of one month or less, hypoxemic respiratory failure with a PaO2<60 mm Hg or arterial saturation on room air <90%, diffuse pulmonary opacaties on X-Ray, BAL with >25% eosinophils, and absence of known causes of eosinophilic pneumonia. Treatment of AEP is high dose steroids with rapid improvement usually seen.

CONCLUSIONS: AEP should be considered early on in a patient clinically presenting with acute hypoxemic respiratory failure requiring mechanical ventilation as the response to high dose steroid administration in this disorder is dramatic and often life-saving.

Reference #1: Rose, D, et al. (2013). Primary eosinophilic lung diseases. Allergy Asthma Proceedings 34: 19-25.

Reference #2: Campos, Luiz Eduardo Mendes, & Pereira, Luiz Fernando Ferreira. (2009). Pulmonary eosinophilia. Jornal Brasileiro de Pneumologia, 35(6), 561-573

DISCLOSURE: The following authors have nothing to disclose: Michael Megally, Aveena Kochar, Jordan Taillon, George Juan, Anu Thomas, Jeremy Weingarten

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