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{{Eosinophilic pneumonia}}
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==Overview==
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) ====
* 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 [[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.
 
==== Tropical pulmonary eosinophilia ====
* [[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.
 
==== Eosinophilic granulomatosis with polyangitis ====
* 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.
 
==== Allergic bronchopulmonary aspergillosis ====
* Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction that occurs when [[Airway|airways]] become colonized by ''Aspergillus.'' 
* 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.
 
==== 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:
* [[Nonsteroidal anti-inflammatory drugs|Nonsteroidal anti-inflammatory drugs (NSAIDs)]]
* [[Anticonvulsant|Anticonvulsants]]
* [[Antidepressants]]
* [[ACE inhibitor|Angiotensin converting enzyme inhibitors]]
* [[Beta blockers]]
* [[Hydrochlorothiazide]]
* [[Sulfa-containing antibiotics|Sulfa-containing compounds]]
{| class="wikitable"
!
!Clinical Picture
!Laboratory diagnosis
!Imaging
!Pulmonary function tests
!Treatment
|-
|Acute eosinophilic pneumonia
|
* Onset <1 month
* Acute onset of [[dyspnea]]
* [[Fever]]
* [[Cough]]
* [[Pleuritic pain]]
* [[Myalgia|Myalgias]]
* [[Acute respiratory distress syndrome]]
|
* 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
|
* A mildly restrictive ventilatory defect
* Reduced [[carbon monoxide]] transfer capacity
* [[Hypoxemia]]
* A PaO2/FiO2 300 mm Hg)
|
* [[Corticosteroids|Systemic corticosteroids]] for 2 weeks
* A starting dose of [[Prednisone|oral prednisone]] of 30 mg per day, or 1 to 2 mg/kg per day
* IAEP does not relapse
|-
|Chronic eosinophilic pneumonia
|
* Onset >2–4 week
 
* [[Dyspnea]]
* [[Cough]]
* [[Rhinitis]] or [[Rhinosinusitis|sinusitis]]
* [[Wheeze|Wheezes]]
* [[Fatigue]]
* [[Malaise]]
* [[Fever]]
|
* Peripheral blood [[eosinophilia]] 6000/mm3
|
* Bilateral [[Alveolus|alveolar]] infiltrates with ill-defined margins
* Ground-glass opacities
* Septal line thickening
* [[Mediastinal lymph node|Mediastinal lymphadenopathy]]
* [[Pleural effusion]]
|
* Airflow obstruction, and the other half have a [[Restrictive lung disease|restrictive ventilatory defect]]
 
* Mild [[hypoxemia]]
|
* [[Corticosteroids|Oral corticosteroids]]
* 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 [[Corticosteroid|corticosteroids]]
|-
|Allergic bronchopulmonary aspergillosis
|
* Stages of ABPA:
* [[Acute (medicine)|Acute]]
* Remission
* Recurrent exacerbations
* [[Corticosteroid]]-dependent [[asthma]]
* Fibrotic end stage RF
* Chronic [[cough]]
* [[Dyspnea]]
* Low-grade [[fever]]
* Chronic [[rhinitis]]
|
* [[Eosinophil granulocyte|Eosinophils]] greater than 1000/ mm
* Total and [[Aspergillus]]-specific IgE levels increase
* sputum examination
* [[Mycelium|Fungal mycelia]] can be found
* Sputum cultures often positive for [[Pseudomonas aeruginosa]] if [[bronchiectasis]] occurs
|
* Central cylindrical [[bronchiectasis]]
* [[Bronchial|Bronchial wall]] thickening
* [[Mucus|Mucus plugging]]: “finger-in-glove” pattern
* Ground-glass attenuation
* Airspace [[Consolidation (medicine)|consolidation]]
* [[Bronchiolitis]]: tree-in-bud pattern
* Centrilobular [[Nodule (medicine)|nodules]]  
|
|
* The mainstay of treatment for ABPA is the use of [[Corticosteroid|corticosteroids]]
* [[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
* High-dose [[methylprednisolone]] may be used in refractory ABPA
* [[Itraconazole|Oral itraconazole]] for 16 to 32 weeks
* [[Omalizumab]] with difficult [[asthma]]
|-
|Eosinophilic granulomatosis with polyangitis
|3 phases:
* [[Rhinosinusitis]] and [[asthma]]
* Blood and tissue [[eosinophilia]],
* Systemic [[vasculitis]]
 
* [[Asthma]] is always present in EGPA
* [[Rhinitis|Chronic rhinitis]] in 75% of cases
* Chronic paraseptal [[Rhinosinusitis|sinusitis]] and nasal [[Polyp|polyposis]]
* [[Asthenia]], weight loss, [[fever]], [[Arthralgia|arthralgias]]
* [[Glomerulonephritis]]
* [[Myocarditis|Eosinophilic myocarditis]] and coronary arteritis may cause [[Congestive heart failure|heart failure]]
|
* Peripheral blood [[eosinophilia]]: Between 5 and
20,000/mm
* [[Bronchoalveolar lavage]] showing [[eosinophilia]] greater than 25% and usually greater than 40%
 
* Increase in [[IgE|serum IgE]] and [[C-reactive protein]]
 
* [[Anti-neutrophil cytoplasmic antibody|ANCAs]] are found in only 40% of patients
|
* Pulmonary infiltrates: ill-defined opacities with peripheral predominance
 
* Ground-glass opacities
* Airspace [[Consolidation (medicine)|consolidation]]
* Centrilobular [[Nodule (medicine)|nodules]]
* Bronchial wall thickening
 
* Interlobular septal thickening
* Hilar or [[mediastinal lymphadenopathy]]
* [[Pleural effusion]]
|
* Airflow obstruction is present in 70% of patients
* Mild airflow obstruction may persist in 30% to 40% of patients
|
* [[Corticosteroid|Corticosteroids]]
* A dose of 1 mg/kg per day for 3 to 4 weeks
An initial [[methylprednisolone]]
 
bolus (15 mg/kg per day for 1–3 days) may be
 
indicated in the most severe cases.
* Subcutaneous [[interferon]]
* High-dose [[Intravenous immunoglobulin|intravenous immunoglobulins]]
* Plasma exchange
* [[Cyclosporine]]
* [[Rituximab]]
* Approximately 25% of patients experience at least 1 relapse
* The 5-year overall survival in EGPA is currently greater than 95
* [[Heart|Cardiac]] involvement
* “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  
|}


==References==
==References==
{{Reflist|2}}
{{reflist|2}}


[[Category:Needs content]]
[[Category:Disease]]
[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Infectious disease]]
 
[[Category:Pneumonia|Pneumonia]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
{{WH}}
{{WS}}

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

Template:WH Template:WS