3/28/17 Resident Morning Report – Eosinophilia, Eosinophilic Pneumonia

CC: dyspnea

ID: 40 yo female presents with 7 weeks of progressively worsening dyspnea and non-productive cough that have persisted despite a course of azithromycin.  She was found to have diminished breath sounds bilaterally and a CBC with WBC of 20.3 and 43% eosinophils.  She denied any recent travels, but admits to frequent “purification rundown” treatments with the Church of Scientology.  She underwent a BAL that showed predominant eosinophils and a thoracentesis with 85% eosinophils.  She was ultimately diagnosed with chronic eosinophilic pneumonia, thought to be secondary to her purification treatments (high doses of niacin).  She was started on steroids with improvement in symptoms; however, each time she stopped steroid therapy and got more purification treatments, her symptoms would flare up.

Don’t forget:

The causes for peripheral eosinophilia can be broadly categorized into 2 mnemonics: CHINA or NAACP.

• C – connective tissue disease
• H – helminthic disease
• I – idiopathic/iatrogenic
• N – neoplastic
• A – allergic/asthma

• N – neoplastic
• A – allergic
• A – asthma/atopic
• C – connective tissue disease
• P – parasites

Pearls from morning report:

• An absolute eosinophil count (AEC) > 20,000 should raise suspicion for malignancy.
• Bacterial infections very rarely cause eosinophilia.
• > 25% eosinophils on BAL is suggestive of a diagnosis of acute eosinophilic pneumonia, and > 40% for chronic eosinophilic pneumonia.
• Chronic eosinophilic pneumonia may appear on CXR as ‘photographic negative of pulmonary edema’ and is considered pathognomonic for the disease.

Random trivia:

Purification rundown treatments were developed by the Church of Scientology founder L. Ron Hubbard.  The goal goal was designed to remove LSD from the body using a restricted diet and large doses of vitamins.

Want to read more?

Eosinophilia (The New England Journal of Medicine)
Eosinophilic Lung Disease (Clinical Chest Medicine)

References: 

Weller PF, Klion AD, Mahoney DH, Bochner BS, Rosmarin AG, Feldweg AM. Approach to the patient with unexplained eosinophilia. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on March 28, 2017)

Klion AD, Weller PF, Bochner BS, Hollingsworth H. Causes of pulmoanry eosinophilia. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on March 28, 2017)