Eosinophilic pneumonia differential diagnosis: Difference between revisions

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{{Eosinophilic pneumonia}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Eosinophilic_pneumonia]]
{{CMG}}
{{CMG}}


==Overview==
==Overview==
Acute eosinophilic pneumonia may be differentiated from other causes of pulmonary eosinophilia
Acute eosinophilic pneumonia may be differentiated from other causes of [[Eosinophilia|pulmonary eosinophilia]] such as acute eosinophilic pneumonia, the transpulmonary passage of [[Parasitic worm|helminth]] larvae (Löffler syndrome), [[Eosinophilia|tropical pulmonary eosinophilia]], eosinophilic granulomatosis with polyangiitis, [[Aspergillosis|allergic bronchopulmonary aspergillosis]], and drugs and toxins.
 
==Differential Diagnosis==
Acute eosinophilic pneumonia may be differentiated from other causes of [[Eosinophilia|pulmonary eosinophilia]].


==== Acute eosinophilic pneumonia (AEP) ====
==== Acute eosinophilic pneumonia (AEP) ====
* The cause of acute eosinophilic pneumonia is unknown.
* The cause of acute eosinophilic pneumonia is unknown.
* Some investigators have suggested that AEP is an acute hypersensitivity reaction to an unidentified inhaled antigen in an otherwise healthy individual [1].
* Some investigators have suggested that AEP is an acute [[hypersensitivity]] reaction to an unidentified inhaled [[antigen]] in an otherwise healthy individual.


==== Transpulmonary passage of helminth larvae (Löffler syndrome) ====
==== Transpulmonary passage of helminth larvae (Löffler syndrome) ====
* Three types of helminths, ''Ascaris (A. lumbricoides'', ''A. suum''), hookworms (''Ancylostoma duodenale'', ''Necator americanus''), and ''Strongyloides stercoralis'', have larvae that reach the lungs, penetrate into alveoli, and ascend the airways then reach the gastrointestinal tract. [10]
* Three types of [[Parasitic worm|helminths]], ''Ascaris (A. lumbricoides'', ''A. suum''), [[Hookworm|hookworms]] (''Ancylostoma duodenale'', ''Necator americanus''), and ''Strongyloides stercoralis'', have larvae that reach the [[Lung|lungs]], penetrate into [[Pulmonary alveolus|alveoli]], and ascend the airways then reach the [[gastrointestinal tract]].  
* ''Ascaris'' is the most common cause of Löffler syndrome worldwide. [11]
* ''Ascaris'' is the most common cause of Löffler syndrome worldwide.  


==== Tropical pulmonary eosinophilia ====
==== Tropical pulmonary eosinophilia ====
* Tropical pulmonary eosinophilia is immune response to the bloodborne microfilarial stages of the lymphatic filariae and Wuchereria bancrofti. [16-18].
* [[Tropical pulmonary eosinophilia]] is immune response to the bloodborne microfilarial stages of the [[Filaria|lymphatic filariae]] and [[Wuchereria bancrofti]].
* The typical symptoms are cough, breathlessness, wheezing, fatigue, and fever. Pulmonary function tests may show a mixed restrictive and obstructive abnormality with a reduction in diffusion capacity. [18]
* The typical symptoms are cough, breathlessness, wheezing, fatigue, and fever. Pulmonary function tests may show a mixed restrictive and obstructive abnormality with a reduction in diffusion capacity.  


==== Eosinophilic granulomatosis with polyangitis ====
==== Eosinophilic granulomatosis with polyangitis ====
* Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) is a vasculitic disorder often characterized by sinusitis, asthma, and prominent peripheral blood eosinophilia. [49]
* Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) is a vasculitic disorder often characterized by [[Rhinosinusitis|sinusitis]], [[asthma]], and prominent peripheral blood [[eosinophilia]].  
* It is the sole form of vasculitis that is associated with both eosinophilia and frequent lung involvement. In addition to the lungs, the skin and the cardiovascular, gastrointestinal, renal, and neurologic systems may also be involved.
* It is the sole form of [[vasculitis]] that is associated with both [[eosinophilia]] and frequent lung involvement. In addition to the lungs, the skin and the cardiovascular, gastrointestinal, renal, and neurologic systems may also be involved.


==== Allergic bronchopulmonary aspergillosis ====
==== Allergic bronchopulmonary aspergillosis ====
* Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction that occurs when airways become colonized by ''Aspergillus.'' [51]
* Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction that occurs when [[Airway|airways]] become colonized by ''Aspergillus.'' 
* Repeated episodes of bronchial obstruction, inflammation, and mucoid impaction can lead to bronchiectasis, fibrosis, and respiratory compromise.
* Repeated episodes of [[Bronchial|bronchial obstruction]], [[inflammation]], and mucoid impaction can lead to [[bronchiectasis]], [[fibrosis]], and respiratory compromise.
* Immunologic responses elicited by ''Aspergillus fumigatus'' are responsible for this syndrome.
* Immunologic responses elicited by ''Aspergillus fumigatus'' are responsible for this syndrome.


==== Drugs and toxins ====
==== Drugs and toxins ====
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a drug-induced hypersensitivity reaction that includes skin eruption, eosinophilia, atypical lymphocytosis, lymphadenopathy, and kidney involvement. Drugs causing DRESS are:
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a drug-induced hypersensitivity reaction that includes skin eruption, [[eosinophilia]], atypical lymphocytosis, [[lymphadenopathy]], and kidney involvement. Drugs causing DRESS are:
* Nonsteroidal anti-inflammatory drugs (NSAIDs) [26]
* [[Nonsteroidal anti-inflammatory drugs|Nonsteroidal anti-inflammatory drugs (NSAIDs)]]  
* anticonvulsants
* [[Anticonvulsant|Anticonvulsants]]
* antidepressants
* [[Antidepressants]]
* angiotensin converting enzyme inhibitors
* [[ACE inhibitor|Angiotensin converting enzyme inhibitors]]
* beta blockers
* [[Beta blockers]]
* hydrochlorothiazide
* [[Hydrochlorothiazide]]
* sulfa-containing compounds [27]
* [[Sulfa-containing antibiotics|Sulfa-containing compounds]]
 
==Differential Diagnosis==
{| class="wikitable"
{| class="wikitable"
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* Onset <1 month
* Onset <1 month
* acute onset of dyspnea
* Acute onset of [[dyspnea]]
* fever
* [[Fever]]
* cough
* [[Cough]]
* pleuritic pain
* [[Pleuritic pain]]
* myalgias
* [[Myalgia|Myalgias]]
* acute respiratory distress syndrome
* [[Acute respiratory distress syndrome]]
|
|
* BAL eosinophilia is often the key to the diagnosis of IAEP.
* Bronchoalveolar lavage showing [[eosinophilia]] is often the key to the diagnosis of IAEP.
* BAL eosinophilia may persist for several weeks.
* Bronchoalveolar lavage showing [[eosinophilia]] may persist for several weeks.
|
|
* bilateral infiltrates
* Bilateral infiltrates
* poorly defined nodules
* Poorly defined nodules
* ground-glass attenuation
* Ground-glass attenuation
* interlobular septal thickening
* Interlobular septal thickening
* bilateral pleural effusion  
* Bilateral [[pleural effusion]]
* Thickening of bronchovascular bundles
* Thickening of bronchovascular bundles
|
|
* a mild restrictive ventilatory defect
* A mildly restrictive ventilatory defect
* reduced carbon monoxide transfer capacity
* Reduced [[carbon monoxide]] transfer capacity
* hypoxemia
* [[Hypoxemia]]
* a PaO2/FiO2 300 mm Hg)
* A PaO2/FiO2 300 mm Hg)
|
|
* systemic corticosteroids for 2 weeks
* [[Corticosteroids|Systemic corticosteroids]] for 2 weeks
* starting dose of oral prednisone of 30 mg per day, or 1 to 2 mg/kg per day
* A starting dose of [[Prednisone|oral prednisone]] of 30 mg per day, or 1 to 2 mg/kg per day
* IAEP does not relapse
* IAEP does not relapse
|-
|-
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* Onset >2–4 week
* Onset >2–4 week


* Dyspnea
* [[Dyspnea]]
* Cough
* [[Cough]]
* rhinitis or sinusitis  
* [[Rhinitis]] or [[Rhinosinusitis|sinusitis]]
* Wheezes
* [[Wheeze|Wheezes]]
* fatigue
* [[Fatigue]]
* malaise
* [[Malaise]]
* fever
* [[Fever]]
|
|
* peripheral blood eosinophiliais 6000/mm3
* Peripheral blood [[eosinophilia]] 6000/mm3
|
|
* bilateral alveolar infiltrates with ill-defined margins
* Bilateral [[Alveolus|alveolar]] infiltrates with ill-defined margins
* ground-glass opacities
* Ground-glass opacities
* Septal line thickening
* Septal line thickening
* mediastinal lymphadenopathy
* [[Mediastinal lymph node|Mediastinal lymphadenopathy]]
* pleural effusion
* [[Pleural effusion]]
|
|
* airflow obstruction, and the other half have a restrictive ventilatory defect
* Airflow obstruction, and the other half have a [[Restrictive lung disease|restrictive ventilatory defect]]


* mild hypoxemia.
* Mild [[hypoxemia]]
|
|
* oral corticosteroids
* [[Corticosteroids|Oral corticosteroids]]
* initial dose of 0.5 mg/kg per day of oral prednisone for 2 weeks
* Initial dose of 0.5 mg/kg per day of [[Prednisone|oral prednisone]] for 2 weeks
* Relapses occur in more than half the patients while decreasing or after stopping corticosteroids
* Relapses occur in more than half the patients while decreasing or after stopping [[Corticosteroid|corticosteroids]]
|-
|-
|Allergic bronchopulmonary aspergillosis
|Allergic bronchopulmonary aspergillosis
|
|
* stages of ABPA:
* Stages of ABPA:
* acute
* [[Acute (medicine)|Acute]]
* remission
* Remission
* recurrent exacerbations
* Recurrent exacerbations
* corticosteroid-dependent asthma
* [[Corticosteroid]]-dependent [[asthma]]
* fibrotic end stage
* Fibrotic end stage RF
* RF
* Chronic [[cough]]
* chronic cough
* [[Dyspnea]]
* dyspnea
* Low-grade [[fever]]
* low-grade fever
* Chronic [[rhinitis]]
* chronic rhinitis
|
|
* Eosinophils greater than 1000/ mm
* [[Eosinophil granulocyte|Eosinophils]] greater than 1000/ mm
* Total and Aspergillus-specific IgE levels increase  
* Total and [[Aspergillus]]-specific IgE levels increase  
* sputum examination:
* sputum examination
* Fungal mycelia can be found
* [[Mycelium|Fungal mycelia]] can be found
* sputum cultures often positive for Pseudomonas aeruginosa if bronchiectasis occurs
* Sputum cultures often positive for [[Pseudomonas aeruginosa]] if [[bronchiectasis]] occurs
|
|
* central cylindrical bronchiectasis
* Central cylindrical [[bronchiectasis]]
* bronchial wall thickening
* [[Bronchial|Bronchial wall]] thickening
* mucous plugging: “finger-in-glove” pattern
* [[Mucus|Mucus plugging]]: “finger-in-glove” pattern
* ground-glass attenuation
* Ground-glass attenuation
* airspace consolidation.
* Airspace [[Consolidation (medicine)|consolidation]]
* Bronchiolitis: tree-in-bud pattern
* [[Bronchiolitis]]: tree-in-bud pattern
* centrilobular nodules and
* Centrilobular [[Nodule (medicine)|nodules]]
|
|
|
|
* The mainstay of treatment for ABPA is the use of corticosteroids
* The mainstay of treatment for ABPA is the use of [[Corticosteroid|corticosteroids]]
* oral prednisolone: 0.5 mg kg per day for 2 weeks  
* [[Prednisolone|Oral prednisolone]]: 0.5 mg kg per day for 2 weeks  
* followed by 0.5 mg kg per day on alternate days for 8 weeks
* Followed by 0.5 mg kg per day on alternate days for 8 weeks
* high-dose methylprednisolone may be used in refractory ABPA
* High-dose [[methylprednisolone]] may be used in refractory ABPA
* Oral itraconazole for 16 to 32 weeks
* [[Itraconazole|Oral itraconazole]] for 16 to 32 weeks
* omalizumab with difficult asthma
* [[Omalizumab]] with difficult [[asthma]]
|-
|-
|Eosinophilic granulomatosis with polyangitis
|Eosinophilic granulomatosis with polyangitis
|3 phases:
|3 phases:
* rhinosinusitis and asthma
* [[Rhinosinusitis]] and [[asthma]]
* blood and tissue eosinophilia,  
* Blood and tissue [[eosinophilia]],  
* systemic vasculitis
* Systemic [[vasculitis]]


* Asthma is always present in EGPA,
* [[Asthma]] is always present in EGPA  
* Chronic rhinitis in 75% of cases
* [[Rhinitis|Chronic rhinitis]] in 75% of cases
* chronic paraseptal sinusitis and nasal polyposis
* Chronic paraseptal [[Rhinosinusitis|sinusitis]] and nasal [[Polyp|polyposis]]
* asthenia, weight loss, fever, arthralgias,
* [[Asthenia]], weight loss, [[fever]], [[Arthralgia|arthralgias]]
* Glomerulonephritis
* [[Glomerulonephritis]]
* Eosinophilic myocarditis and coronary arteritis may cause heart failure
* [[Myocarditis|Eosinophilic myocarditis]] and coronary arteritis may cause [[Congestive heart failure|heart failure]]
|
|
* Peripheral blood eosinophilia: Between 5 and
* Peripheral blood [[eosinophilia]]: Between 5 and
20,000/mm
20,000/mm
* BAL eosinophilia greater than 25% and usually greater than 40%
* [[Bronchoalveolar lavage]] showing [[eosinophilia]] greater than 25% and usually greater than 40%


* Increase in serum IgE and C-reactive protein
* Increase in [[IgE|serum IgE]] and [[C-reactive protein]]


* ANCAs are found in only 40% of patients
* [[Anti-neutrophil cytoplasmic antibody|ANCAs]] are found in only 40% of patients
|
|
* Pulmonary infiltrates: ill-defined opacities with peripheral predominance
* Pulmonary infiltrates: ill-defined opacities with peripheral predominance


* ground-glass opacities  
* Ground-glass opacities  
* airspace consolidation.
* Airspace [[Consolidation (medicine)|consolidation]]
* centrilobular nodules
* Centrilobular [[Nodule (medicine)|nodules]]
* bronchial wall thickening
* Bronchial wall thickening


* Interlobular septal thickening
* Interlobular septal thickening
* hilar or mediastinal lymphadenopathy
* Hilar or [[mediastinal lymphadenopathy]]
* pleural effusion
* [[Pleural effusion]]
|
|
* Airflow obstruction is present in 70% of patients
* Airflow obstruction is present in 70% of patients
* mild airflow obstruction may persist in 30% to 40% of patients
* Mild airflow obstruction may persist in 30% to 40% of patients
|
|
* Corticosteroids
* [[Corticosteroid|Corticosteroids]]
* dose of 1 mg/kg per day for 3 to 4 weeks
* A dose of 1 mg/kg per day for 3 to 4 weeks
An initial methylprednisolone
An initial [[methylprednisolone]]


bolus (15 mg/kg per day for 1–3 days) may be
bolus (15 mg/kg per day for 1–3 days) may be


indicated in the most severe cases.
indicated in the most severe cases.
* Subcutaneous interferon-
* Subcutaneous [[interferon]]
* high-dose intravenous immunoglobulins
* High-dose [[Intravenous immunoglobulin|intravenous immunoglobulins]]
* plasma exchange
* Plasma exchange
* cyclosporine
* [[Cyclosporine]]
* rituximab
* [[Rituximab]]
* Approximately 25% of patients experience at least 1 relapse
* Approximately 25% of patients experience at least 1 relapse
* The 5-year overall survival in EGPA is currently greater than 95
* The 5-year overall survival in EGPA is currently greater than 95
* cardiac involvement
* [[Heart|Cardiac]] involvement
* “poor prognostic” criteria:   age older than 65 years;  cardiac symptoms; gastrointestinal involvement;  renal insufficiency with serum creatinine greater  than 150 mg/L; and absence of ear, nose, and  throat manifestations.159,162  
* “Poor prognostic” criteria: Age older than 65 years;  [[Heart|cardiac]] symptoms; [[Gastrointestinal|gastrointestinal involvement]][[renal insufficiency]] with [[Creatinine|serum creatinine]] greater  than 150 mg/L; and absence of ear, nose, and  throat manifestation  
|}
|}



Latest revision as of 20:25, 19 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Acute eosinophilic pneumonia may be differentiated from other causes of pulmonary eosinophilia such as acute eosinophilic pneumonia, the transpulmonary passage of helminth larvae (Löffler syndrome), tropical pulmonary eosinophilia, eosinophilic granulomatosis with polyangiitis, allergic bronchopulmonary aspergillosis, and drugs and toxins.

Differential Diagnosis

Acute eosinophilic pneumonia may be differentiated from other causes of pulmonary eosinophilia.

Acute eosinophilic pneumonia (AEP)

  • The cause of acute eosinophilic pneumonia is unknown.
  • Some investigators have suggested that AEP is an acute hypersensitivity reaction to an unidentified inhaled antigen in an otherwise healthy individual.

Transpulmonary passage of helminth larvae (Löffler syndrome)

  • Three types of helminthsAscaris (A. lumbricoidesA. suum), hookworms (Ancylostoma duodenaleNecator americanus), and Strongyloides stercoralis, have larvae that reach the lungs, penetrate into alveoli, and ascend the airways then reach the gastrointestinal tract.
  • Ascaris is the most common cause of Löffler syndrome worldwide.

Tropical pulmonary eosinophilia

Eosinophilic granulomatosis with polyangitis

  • Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) is a vasculitic disorder often characterized by sinusitis, asthma, and prominent peripheral blood eosinophilia.
  • It is the sole form of vasculitis that is associated with both eosinophilia and frequent lung involvement. In addition to the lungs, the skin and the cardiovascular, gastrointestinal, renal, and neurologic systems may also be involved.

Allergic bronchopulmonary aspergillosis

  • Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction that occurs when airways become colonized by Aspergillus. 
  • Repeated episodes of bronchial obstruction, inflammation, and mucoid impaction can lead to bronchiectasis, fibrosis, and respiratory compromise.
  • Immunologic responses elicited by Aspergillus fumigatus are responsible for this syndrome.

Drugs and toxins

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a drug-induced hypersensitivity reaction that includes skin eruption, eosinophilia, atypical lymphocytosis, lymphadenopathy, and kidney involvement. Drugs causing DRESS are:

Clinical Picture Laboratory diagnosis Imaging Pulmonary function tests Treatment
Acute eosinophilic pneumonia
  • Bronchoalveolar lavage showing eosinophilia is often the key to the diagnosis of IAEP.
  • Bronchoalveolar lavage showing eosinophilia may persist for several weeks.
  • Bilateral infiltrates
  • Poorly defined nodules
  • Ground-glass attenuation
  • Interlobular septal thickening
  • Bilateral pleural effusion
  • Thickening of bronchovascular bundles
Chronic eosinophilic pneumonia
  • Onset >2–4 week
Allergic bronchopulmonary aspergillosis
Eosinophilic granulomatosis with polyangitis 3 phases:

20,000/mm

  • ANCAs are found in only 40% of patients
  • Pulmonary infiltrates: ill-defined opacities with peripheral predominance
  • Airflow obstruction is present in 70% of patients
  • Mild airflow obstruction may persist in 30% to 40% of patients

An initial methylprednisolone

bolus (15 mg/kg per day for 1–3 days) may be

indicated in the most severe cases.

References

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