Eosinophilic pneumonia


Eosinophilic pneumonia EP is a disease in which an eosinophil, a type of white blood cell, accumulates in the lung These cells cause disruption of the normal air spaces alveoli where oxygen is extracted from the atmosphere Several different kinds of eosinophilic pneumonia exist and can occur in any age group The most common symptoms include cough, fever, difficulty breathing, and sweating at night EP is diagnosed by a combination of characteristic symptoms, findings on a physical examination by a health provider, and the results of blood tests and x-rays Prognosis is excellent once most EP is recognized and treatment with corticosteroids is begun

Contents

  • 1 Classification
  • 2 Signs and symptoms
  • 3 Pathophysiology
    • 31 Medications and environmental exposures
    • 32 Parasitic infections
    • 33 AEP and CEP
  • 4 Diagnosis
    • 41 Differential diagnosis
  • 5 Treatment
  • 6 Prognosis
  • 7 Epidemiology
    • 71 History
  • 8 References
  • 9 See also

Classificationedit

Eosinophilic pneumonia is divided into different categories depending upon whether a cause can be determined or not Known causes include certain medications or environmental triggers, parasitic infections, and cancer EP can also occur when the immune system attacks the lungs, a disease called eosinophilic granulomatosis with polyangiitis When a cause cannot be found, the EP is labeled "idiopathic" Idiopathic EP can be divided into "acute eosinophilic pneumonia" AEP and "chronic eosinophilic pneumonia" CEP depending on the symptoms a person is experiencing1

Signs and symptomsedit

Most types of eosinophilic pneumonia have similar signs and symptoms Prominent and nearly universal signs and symptoms include cough, fever, difficulty breathing, and night sweats Acute eosinophilic pneumonia typically follows a rapid course Fever and cough may develop only one or two weeks before breathing difficulties progress to the point of respiratory failure requiring mechanical ventilation Chronic eosinophilic pneumonia usually follows a slower course Symptoms accumulate over several months and include fever, cough, difficulty breathing, wheezing, and weight loss Individuals with CEP are often misdiagnosed with asthma before CEP is finally recognized

EP due to medications or environmental exposures is similar and occurs after an exposure to a known offending agent EP due to parasitic infections has a similar prodrome in addition to a host of different symptoms related to the variety of underlying parasites EP in the setting of cancer often develops in the context of a known diagnosis of lung cancer, cervical cancer, etc

Pathophysiologyedit

Eosinophilic pneumonia can develop in several different ways depending on the underlying cause of the disease Eosinophils play a central role in defending the body against infection by parasites Many diseases, such as asthma and eczema, are caused when eosinophils overreact to environmental triggers and release an excess of chemicals, eg cytokines and histamine The common characteristic among different causes of EP is eosinophil overreaction or dysfunction in the lung

Medications and environmental exposuresedit

Medications, substance abuse, and environmental exposures may all trigger eosinophil dysfunction Medications such as NSAIDs ie ibuprofen, nitrofurantoin, phenytoin, L-tryptophan, daptomycin2 and ampicillin and drugs of abuse such as inhaled heroin and cocaine may trigger an allergic response which results in EP Chemicals such as sulfites, aluminum silicate, and cigarette smoke can cause EP when inhaled A New York City firefighter developed EP after inhalation of dust from the World Trade Center on September 11, 20013

Parasitic infectionsedit

Parasites cause EP in three different ways Parasites can either invade the lung, live in the lung as part of their life cycle, or be spread to the lung by the bloodstream Eosinophils migrate to the lung in order to fight the parasites and EP results Important parasites which invade the lung include Paragonimus lung flukes and the tapeworms Echinococcus and Taenia solium Important parasites which inhabit the lung as part of their normal life cycle include the worms helminths Ascaris lumbricoides, Strongyloides stercoralis and the hookworms Ancylostoma duodenale and Necator americanus When EP is caused by this last group, it is often called "Löffler's syndrome" The final group of parasites cause EP when a large number of eggs are carried into the lungs by the bloodstream This can include Trichinella spiralis, Strongyloides stercoralis, Ascaris lumbricoides, the hookworms, and the schistosomes4

AEP and CEPedit

The causes for both AEP and CEP are unknown as of 2005 There is some suspicion that at least AEP is the result of the body's response to some unidentified environmental agent

Diagnosisedit

Eosinophilic pneumonia is diagnosed in one of three circumstances: when a complete blood count reveals increased eosinophils and a chest x-ray or computed tomography CT identifies abnormalities in the lung, when a biopsy identifies increased eosinophils in lung tissue, or when increased eosinophils are found in fluid obtained by a bronchoscopy bronchoalveolar lavage BAL fluid Association with medication or cancer is usually apparent after review of a person's medical history Specific parasitic infections are diagnosed after examining a person's exposure to common parasites and performing laboratory tests to look for likely causes If no underlying cause is found, a diagnosis of AEP or CEP is made based upon the following criteria AEP is most likely with respiratory failure after an acute febrile illness of usually less than one week, changes in multiple areas and fluid in the area surrounding the lungs on a chest x-ray, and greater than 25% eosinophils on a BAL Other typical laboratory abnormalities include an elevated white blood cell count, erythrocyte sedimentation rate, and immunoglobulin G level Pulmonary function testing usually reveals a restrictive process with reduced diffusion capacity for carbon monoxide CEP is most likely when the symptoms have been present for more than a month Laboratory tests typical of CEP include increased blood eosinophils, a high erythrocyte sedimentation rate, iron deficiency anemia, and increased platelets A chest x-ray can show abnormalities anywhere, but the most specific finding is increased shadow in the periphery of the lung, away from the heart

Differential diagnosisedit

This includes:

  • Asthma
  • Environmental allergic reaction
  • Eosinophilic granulomatosis with polyangiitis Wegner's syndrome
  • Allergic bronchopulmonary aspergillosis
  • Churg-Strauss syndrome
  • Loeffler's syndrome
  • Acute eosinophilic pneumonia
  • Chronic eosinophilic pneumonia Carrington's disease
  • Polyarteritis nodosa
  • Parasitic infections
  • Tropical pulmonary eosinophilia
  • Tuberculosis
  • Fungal infection
  • Sarcoidosis
  • Drug reaction with eosinophilia and systemic symptoms
  • Mastocytosis
  • Lymphoproliferative hypereosinophilic syndrome
  • Myeloproliferative hypereosinophilic syndrome

Treatmentedit

When eosinophilic pneumonia is related to an illness such as cancer or parasitic infection, treatment of the underlying cause is effective in resolving the lung disease When due to AEP or CEP, however, treatment with corticosteroids results in a rapid, dramatic resolution of symptoms over the course of one or two days Either intravenous methylprednisolone or oral prednisone are most commonly used In AEP, treatment is usually continued for a month after symptoms disappear and the x-ray returns to normal usually four weeks total In CEP, treatment is usually continued for three months after symptoms disappear and the x-ray returns to normal usually four months total Inhaled steroids such as fluticasone have been used effectively when discontinuation of oral prednisone has resulted in relapse5 Because EP affects the lungs, individuals with EP have difficulty breathing If enough of the lung is involved, it may not be possible for a person to breathe without support Non-invasive machines such as a bilevel positive airway pressure machine may be used Otherwise, placement of a breathing tube into the mouth may be necessary and a ventilator may be used to help the person breathe

Prognosisedit

Eosinophilic pneumonia due to cancer or parasitic infection carries a prognosis related to the underlying illness AEP and CEP, however, have very little associated mortality as long as intensive care is available and treatment with corticosteroids is given CEP often relapses when prednisone is discontinued; therefore, some people with CEP require lifelong therapy Chronic prednisone is associated with many side effects, including increased infections, weakened bones, stomach ulcers, and changes in appearance6

Epidemiologyedit

Eosinophilic pneumonia is a rare disease Parasitic causes are most common in geographic areas where each parasite is endemic AEP can occur at any age, even in previously healthy children, though most patients are between 20 and 40 years of age Men are affected approximately twice as frequently as women AEP has been associated with smoking CEP occurs more frequently in women than men and does not appear to be related to smoking An association with radiation for breast cancer has been described7

Historyedit

Chronic eosinophilic pneumonia was first described by Carrington8 in 1969, and it is also known as Carrington syndrome Prior to that, eosinophilic pneumonia was a well described pathologic entity usually associated with medication or parasite exposures Acute eosinophilic pneumonia was first described in 1989910

Referencesedit

  1. ^ Bain GA, Flower CD 1996 "Pulmonary eosinophilia" Eur J Radiol 23 1: 3–8 PMID 8872069 doi:101016/0720-048X9601029-7 
  2. ^ http://wwwfdagov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm220273htm
  3. ^ Rom WN, Weiden M, Garcia R, et al 2002 "Acute eosinophilic pneumonia in a New York City firefighter exposed to World Trade Center dust" Am J Respir Crit Care Med 166 6: 797–800 PMID 12231487 doi:101164/rccm200206-576OC 
  4. ^ Weller PF 1994 "Parasitic pneumonias" In Pennington, James Respiratory infections: diagnosis and management 3rd ed New York: Raven Press p 695 ISBN 0-7817-0173-2 
  5. ^ Jantz MA, Sahn SA 1999 "Corticosteroids in acute respiratory failure" Am J Respir Crit Care Med 160 4: 1079–100 PMID 10508792 doi:101164/ajrccm16049901075 
  6. ^ Naughton M, Fahy J, FitzGerald MX 1993 "Chronic eosinophilic pneumonia A long-term follow-up of 12 patients" Chest 103 1: 162–5 PMID 8031327 doi:101378/chest1031162 
  7. ^ Cottin V, Frognier R, Monnot H, Levy A, DeVuyst P, Cordier JF 2004 "Chronic eosinophilic pneumonia after radiation therapy for breast cancer" Eur Respir J 23 1: 9–13 PMID 14738224 doi:101183/090319360300071303 
  8. ^ Carrington CB, Addington WW, Goff AM, et al 1969 "Chronic eosinophilic pneumonia" N Engl J Med 280 15: 787–98 PMID 5773637 doi:101056/NEJM196904102801501 
  9. ^ Badesch DB, King TE, Schwarz MI 1989 "Acute eosinophilic pneumonia: a hypersensitivity phenomenon" Am Rev Respir Dis 139 1: 249–52 PMID 2912347 doi:101164/ajrccm/1391249 
  10. ^ Allen JN, Pacht ER, Gadek JE, Davis WB 1989 "Acute eosinophilic pneumonia as a reversible cause of noninfectious respiratory failure" N Engl J Med 321 9: 569–74 PMID 2761601 doi:101056/NEJM198908313210903 

See alsoedit

  • Pneumonia
  • Asthma
  • Parasitic pneumonia


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