EOSINOPHILIC PNEUMONIAS different types and methods

Eosinophilic pneumonia , lung
Different types

1. EOSINOPHILIC PNEUMONIAS BY DR AMAL V RAJ

2. INTRODUCTIION ASSOCIATION BETWEEN PULM INFILTRATES AND EOSINOPHILIA – LOEFFLER IN 1932 HETEROGENEOUS GROUP OF DISORDERS ‘ EOSINOPHILS PRECISE ROLE IS NOT CLEAR EOSINOPHILS ROLE IN ABPA VS PARASITIC INFECTIONS

3. DISEASES ASSOCIATED WITH PULMONARY INFILTRATES AND EOSINOPHILIA

4. OTHER DISEASES VARIABLY ASSOCIATED WITH EOSINOPHILIA

5. EOSINOPHILIC PNEUMONIAS WITH ACUTE PRESENTATION LOEFFLER SYNDROME(SIMPLE PULMONARY EOSINOPHILIA) PARASITIC INFECTIONS DRUG AND TOXIN INDUCES PULMONARY EOSINOPHILIC SYNDROMES IDIOPATHIC ACUTE EOSINOPHILIC SYNDROMES

6. SIMPLE PULMONARY EOSINOPHILIA IMMUNE HYPERSENSITIVITY TO PARASTIC INFECTIONS AFFECTS PEOPLE OF ALL AGES CLINICAL FEATURES LOW GRADE FEVER, NON-PRODUCTIVE COUGH, DYSPNOEA, CHEST DISCOMFORT AND OCCASIONALY HEMOPTYSIS

7. LAB INVESTIGATIONS MODERATE TO SEVERE EOSINOPHILIA EXPECTORATED SPUTUM RICH IN EOSINOPHILS AND CHARCOT LEYDEN CRYSTALLS CXR- TRANSIENT, MIGRATORY, NON SEGMENTAL , BILATERAL , INTERSTITIAL AND ALVEOLAR INFILTRATES PFT- MILD TO MODERATE RESTRICTIVE VENTILATORY DEFECT WITH REDUCED DLCO

8. LIFE CYCLE OF ASCARIS LUMBRICOIDES

9. PATHOGENESIS HYPERSENSITIVITY REACTION TO PARASITE LARVAE BEGINS ~9-14 DAYS FOLLOWING LARVAL INGESTION DIAGNOSIS PNEUMONIC PHASE- LARVAE IDENTIFIED IN SPUTUM OR GASTRIC ASPIRATES STOOL NEGATIVE FOR ALMOST 8 WEEKS AFTER PULM SYMPTOMS SEARCH FOR ETIOLOGIC AGENT

10. TREATMENT BRONCHODILATORS AND RARELY CORTICOSTEROIDS RELEIVE PULMONARY SYMPTOMS ASCARIS INDUCED- MEBENDAZOLE 100 MG X 3D OR 500 MG SINGLE DOSE ALTERNATIVES- PYRANTEL PAMOATE, ALBENDAZOLE, IVERMECTIN FOLLOWUP FOR GI SYMPTOMS 2-3 MONTHS

11. PARASITIC INFECTIONS ASSOCIATED WITH EOSINOPHILIC PNEUMONIA

12. DRUG AND TOXIN INDUCED PULMONARY EOSINOPHILIC SYNROMES www.pneumotox.com OTHER THAN DRUGS- RADIATION EXPOSURE, SMOKE OR DUST EXPOSURE , IODINATED CONTRAST, COCAINE OR HEROINE INHALTION ACUTE ON SUBACUTE ONSET NOT RELATED TO DOSE OR DURATION OF TREATMENT SYMPTOMS VARY WIDELY IN SEVERITY DRESS SYNDOME

13. INVESTIGATIONS PFT- OBSTRUCTIVE PHYSIOLOGY NOT COMMON CXR- INTERSTITIAL OR ALVEOLAR INFILTRATES HRCT THORAX- BILATERAL CONSOLIDATION AND GGO (PERIPHERAL USUALLY)

14. IDIOPATHIC ACUTE EOSINOPHILIC PNEUMONIA MORE SEVERE AGE 20-40, M>F PREVIOUSLY HEALTHY PATIENTS CHANGED SMOKING HABITS 70% HISTORY OF SMOKING PERSONS WITH UNUSUAL EXPOSURES H1 N1 COCAINE OR HEROINE INFECTION TREATMENT WITH DRUGS(MINOCYCLINE, VENLAFAXINE, DAPTOMYCIN ETC)

15. CLINICAL FEATURES ACUTE ILLNESS WITH FEVER , DYSPNOEA, COUGH, TACHYPNOEA, PLEURITIC CHEST PAIN AND HYPOXIA USUALLY <7 DAYS COURSE- RAPID PROGESSION IS COMMON O/E DIFFUSE INSPIRATORY CACKLES, WHEEZE

16. LAB MODERATE LEUKOCYTOSIS WITH SHIFT TO LEFT EOSINOPHILIA INITIALLY ABSENT SERUM IGE MODERATE ELEVATION ESR ELEVATED TARC/ CCR17 LIGAND STRIKING EOSINOPHILIA IN BAL FLUID(25%-55%) LYMPHOCYTES AND NEUTROPHILS MAY ALSO BE ELEVATED IN BAL FLUID PFT- RESTRICTIVE VENTILATORY DEFECT WITH REDUCE DLCO RESOLVES ON TREATMENT

17. TREATMENT Methyl prednisolone- 60- 125 mgQ6h. Mechanical ventilation. Prednisolone- 40- 60mg 2-4 weeks. RELAPSE IS RARE.

18. TROPICAL PULMONARY EOSINOPHILIA 1 st described in 1940. Weingartan . Syndrome characterized by fever, anorexia paroxysmal dry cough, dyspnoea wheezing and peripheral blood eosinophilia. Filarial endemic regions of the world. Due to hypersensitivity to filarial antigens Early stage-eosinophilic bronchopneumonia. Late stages- Mixed cell inflammation and pulmonary fibrosis

19. Peripheral blood eosinophilia. Sputum & BAL-eosinophilia Microfilaria- Lymphnode or Lung biopsy. CXR- ill defined diffuse reticulo - nodular infiltrate with mottled apperance . Hilar adenopathy, pleural effusion.

20. Spontaneous resolution. DEC-6-12mg/Kg/day x 10-14days (21 Days) Clinical & radio. Improvement 1-3 weeks Relapse can occur. Chronic cases- Oral Corticosteroids. Untreated- pulmonary fibrosis

21. CHRONIC EOSINOPHILIC PNEUMONIA 1969- Carrington. Co- existance of blood eosinophilia with pulmonary eosinophilic infiltration. 30-40 yrs , Female : Male- 2:1. Etiology is unknown. Cough ,Breathlessness, Fever , Wt loss, H/o recent onset asthma-50%. CXR-Peripherally based progressive dense infiltrate- “ PHOTOGRAPHIC NEGATIVE OF PULMONARY OEDEMA”

22. DIAGNOSIC CRITERIA Sub acute onset. Mild hypoxemia. Diffuse ,usually peripheral radiographic infiltrate. Blood & Lung eosinophilia. Absence of parasitic, fungal or other lung infections. No H/O drug reaction. Prompt &Complete response to steroids. Relapse is common after corticosteroid is discontinued

23. CT Thorax-dense peripherally located air space consolidation& mediastinal adenopathy. Lung biopsy –eosinophilic infiltration of interstitial & alveolar spaces, micro-abscess, noncaseating granuloma, noncaseating micro angitis . Treatment- Oral corticosteroids Prednisolone-40mg/dayx10-14 Days; Tapering over 4-6 weeks, low dose for6 months ,

24. ALLERGIC BRONCHO PULMONARY ASPERGILLOSIS 1939-Rackeman &Greene.- PAN&Allergic disease. 1951- Churg & Strauss.- Asthma,Eosinophilia , Vasculitis affecting many organs. Age group- 38-50 yrs,males >females. Clinical phases 1.Prodromal Phase 2. Eosinophilic Phase 3.Vasculitic Phase

25. Clinical Features. Respiratory System URT- Allergic Rhinitis,Sinusitis , Polyposis. LRT- Asthma,CXR -shadows-Migratory infiltrates, Hilar adenopathy, interstititial nodules,Pleurisy & Pl.Effusion . CVS - CCF,Necrotising Vasculitis of coronry arteries,Ischemic cardiomyopathy.pericarditis Neurologic-Mono or polyneuropathy,Subarachnoid hemorrhage, Cerebral infarction.

26. Skin - Purpura,Tender cutaneous or sub cutaneous nodules, urticaria,Livedo reticularis. GIT, Renal. Diagnostic criteria ( American College of Rheumatology) Asthma Blood eosinophilia>10% Mononeuropathy or poly neuropathy CXR Infiltrates. Para nasal sinus abnormalities. Biopsy containing a vessel with extra vascular eosinophils

27. INVESTIGATIONS Peripheral blood eosinophilia. Raised S.Ig E Positive p ANCA. Pleural Bx-eosinophilic infiltration. Histopathology-Eosinophilic infiltration,necrotising vasculitis, granuloma. Association between LT receptor antagonist & CSS. Treatment- Corticosteroids,Azathioprine,Cyclophosphomide .