Pulmonary eosinophilia.pptx

general discussion about Pulmonary eosinophilia.

1. Pulmonary Eosinophilia DR. MD. SHAFIQUL ISLAM DEWAN RESIDENT (PULMONOLOGY) DEPARTMENT OF RESPIRATORY MEDICINE DHAKA MEDICAL COLLEGE HOSPITAL April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

2. Synonymous sentence Pulmonary Eosinophilia Eosinophilic pneumonia Eosinophilic lung diseases April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

3. Causes of pulmonary eosinophilia Idiopathic acute eosinophilic pneumonia Idiopathic chronic eosinophilic pneumonia Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) Others Idiopathic hypereosinophilic syndrome Idiopathic interstitial lung diseases Neoplasms Non-helminthic infections ( eg,Coccidioidomycosis , Mycobacterium tuberculosis) Drug- and toxin-induced eosinophilic lung diseases Nonsteroidal antii-nflammatory drugs (NSAIDs) Antimicrobials (nitrofurantoin, minocycline, sulfonamides, ampicillin, daptomycin) Phenytoin L-tryptophan April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

4. Causes of pulmonary eosinophilia Helminthic and fungal infection-related eosinophilic lung diseases Transpulmonary passage of larvae (Loffler's syndrome) Ascaris lumbricoides Hookworm ( Ancylostoma duodenale, Necator americanus) Strongyloides stercoralis Pulmonary parenchymal invasion - mostly helminths , eg , paragonimiasis Heavy hematogenous seeding with helminths Trichinellosis Disseminated strongyloidiasis Cutaneous and visceral larva migrans Schistosomiasis Tropical pulmonary eosinophilia Wuchereria bancrofti Brugia malayi Allergic bronchopulmonary aspergillosis April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

5. Eosinophilic pneumonia Eosinophilic pneumonia is a pneumonia in which, on histopathologic examination, eosinophils are the most prominent inflammatory cells. Other inflammatory cells, especially lymphocytes and neutrophils, are often associated, but eosinophils clearly predominate. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

6. Defining Characteristics The defining characteristics of pulmonary eosinophilia include the following_ Peripheral blood eosinophilia (absolute eosinophil count ≥500 eosinophils/ microL ) with abnormalities on pulmonary imaging studies Increased eosinophils in bronchoalveolar lavage (BAL) fluid ( eg , >10 percent) Lung tissue eosinophilia demonstrated in transbronchial or open lung biopsies. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

7. Eosinophilia & Hypereosinophila Blood eosinophilia is defined by an eosinophil blood count greater than 0.5 × 109/L (500/ μl ). Hypereosinophila is defined by an eosinophil blood count greater than 1.5 × 109/L (1500/ μl ) on two examinations at least 1 month apart, and/or tissue hypereosinophilia . April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

8. BAL In normal subjects, BAL eosinophils comprise less than 1% of cells. In contrast, BAL eosinophilia greater than 40% is found mainly in patients with chronic eosinophilic pneumonia, whereas BAL eosinophilia from 3–25% (and especially from 3–9% ) may be found in various conditions, such as idiopathic pulmonary fibrosis, interstitial lung disease associated with connective tissue disorders, hypersensitivity pneumonitis, sarcoidosis, radiation pneumonitis, asthma, pneumoconiosis, and infection. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

9. BAL A conservative cutoff of 40% of eosinophils in the BAL has been adopted for the diagnosis of ICEP in clinical studies, and a cutoff of 25% has been proposed for the diagnosis of IAEP. For clinical practice, a diagnosis of eosinophilic pneumonia is supported by alveolar eosinophilia when the eosinophils (1) are the predominant cell population (macrophages excepted) and (2) represent more than 25% of the differential cell count in the BAL. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

10. BAL Although BAL is usually useful and safe in patients with suspected eosinophilic pneumonia, it may not always be mandatory in typical cases with both pulmonary opacities on imaging and markedly elevated peripheral blood eosinophilia (>1 × 109/L and preferably 1.5 × 109/L [1500/ μL ]). April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

11. Interstitial lung disease associated with BAL eosinophilia April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

12. When we suspect Pulmonary Eosinophilia? Diagnosis of eosinophilic pneumonia is suspected in patients presenting with_ Respiratory symptoms (dyspnea, cough, or wheezing), Pulmonary opacities on chest imaging, and Demonstration of eosinophilia in the peripheral blood or, preferably, in the lung. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

13. History and physical examination Medication and chemical exposures , including aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, and antibiotics, as well as exposures to dust, smoke ( eg , firefighting, tobacco smoke, vaping), or chemicals. Travel and immigration histories , including residence in or travel to regions endemic for Coccidioides and varied parasites. History of ingestion of poorly cooked pork, wild boar, or other wild animal meats associated with complaints of muscle pain, tenderness, swelling, and weakness. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

14. History and physical examination Respiratory history and findings , including antecedent or concomitant asthma, as found inallergic bronchopulmonary aspergillosis/mycosis (ABPA/ABPM), eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss), and sometimes chronic eosinophilic pneumonia (CEP) or helminthic etiologies. Duration of any antecedent symptoms should be considered. Acute eosinophilic pneumonia (AEP) is characteristically abrupt in onset, whereas CEP develops insidiously over months. Asthma in EGPA may begin years before the development of vasculitic lung involvement. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

15. History and physical examination Presence of symptoms or signs of extrapulmonary organ involvement , since these may be indicative of systemic diseases, including EGPA, hyper-eosinophilic syndromes, and neoplasms. Physical examination is looking for cutaneous lesions that might indicate a certain diagnosis or provide an opportunity for a less invasive biopsy site. Stigmata of rheumatic diseases ( eg , muscle weakness, joint swelling, or erythema) should be sought. Lung examination is nonspecific, although wheezes would be more consistent with EGPA, CEP,or ABPA, while crackles would be more likely with drug-induced pulmonary eosinophilia, AEP, or less commonly CEP. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

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17. Transbronchial biopsy In general, transbronchial biopsy is less likely to secure a confident diagnosis than surgical lung biopsy. However, when EGPA (Churg-Strauss) is suspected, a definitive diagnosis can sometimes be made on a transbronchial biopsy, thus avoiding a more invasive lung biopsy procedure. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

18. Lung biopsy For causes of pulmonary eosinophilia other than infection, medication, or toxin, it is important to establish and document the nature of the disease. While EGPA, AEP, CEP, and often HES will respond to glucocorticoid therapy, establishing a firm pathologic diagnosis upfront is prudent given the side effects of long-term glucocorticoid treatment and the options for second-line therapy in glucocorticoid-refractory disease. Moreover, since EGPA has the potential to involve and damage other organs, documenting this vasculitis has important implications for the future management of the patient. As with the general evaluation of interstitial lung disease a surgical approach is typically preferred over a transbronchial biopsy due to the small size of transbronchial specimens. Video-assisted thoracoscopic surgery (VATS) can substitute for a thoracotomy to provide tissue. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

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20. The three diseases that could be diagnosed with greatest certainty by HRCT were CEP, ABPA, and AEP. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

21. CT findings of CEP Characteristic CT findings of CEP include: bilateral consolidative opacities and areas of ground-glass attenuation, involving predominantly the peripheral regions of the middle or upper lung zones. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

22. CT findings in AEP CT findings in AEP include: ground-glass attenuation, consolidation, poorly defined nodules, interlobular septal thickening, and pleural effusions. The triad of interlobular septal thickening, bronchovascular bundle thickening, and pleural effusions are most suggestive of this diagnosis April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

23. CT findings of ABPA Common CT findings of ABPA consist of bronchiectasis, mucous plugging, bronchial wall thickening , atelectasis, consolidation, areas of ground-glass attenuation, and upper and central lung predominance. The first three of these findings are the most indicative of ABPA. April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)

24. Thank You April 11, 2023 Dr. Md. Shafiqul Islam Dewan; Resident (Pulmonology)