Q:

3/18/2013
43 yo F Pt with asthma since age 18 yo. She was diagnosed with Rheumatoid arthritis ten years later when developed pleurisy. Allergic asthma with triggers of pets and dust. Has had increase in respiratory symptoms in new home in VA fall of 2012 due to dust when moved in. Hospitalized for pneumonia mid Dec 2012 and treated with 2 courses of Levaquin. Since hospitalization still is SOB and cannot catch her breath, she remained symptomatic when seeing me 3 weeks ago.

Pt reports 3 time history of pneumonia; hospitalized at age 4 yo, then treated for outpatient pneumonia in college and recently hospitalized in for pneumonia. Reports frequent sinusitis and bronchitis since diagnosed with rheumatoid arthritis 3/2005; ie approximately 2-3x/year.

Inpatient course (admitted for 5 days): Influenza testing was positive and placed on Tamiflu and Levaquin. Infectious disease specialist performed sputum culture which was positive for Aspergillus fumigatus, had increasing WBC from 8.9 to 14.6 with 44% PMNs and therefore given a dose of Vancomycin for Staph coverage. Discharged with diagnosis of ‘community acquired Streptococcal pneumonia’. CT chest 12/12 LLL consolidation > R; multifocal pneumonia. Repeat CT chest as outpatient after Levaquin, on 1/13 increase opacity in LUL and decrease patchy opacity in LLL pneumonia Saw pulmonary as outpatient and treated with another course of Levaquin. Her PFT as outpatient was normal with FVC 99%, 107% FEV1, FEV1/FVC 83%, FEF 25-75 of 94%.

Serology ordered by Pulmonary on 2-11-13 with 4655 absolute eosinophils, ie 35%, total IgE elevated at 425, Aspergillus fumigatus IgG 156, and WBC 13 (all abnormally elevated). Aspergillus fumigatus IgE < 0.35 and alpha 1 antitrypsin wnl. Previous labs before hospitalization, 10/26/12 with 1891 or 16% eosinophils and WBC 11.6 with normal ESR of 7. Labs 11-30-12 with 2660 eosinophils, ie 28%, and 9.5 or normal WBC. Quantitative immunoglobulins, Tetanus, hib titers normal. Pneumococcal titers subtherapeutic in 19 of 23. Food allergies to egg. Repeat CT chest 3/13 with resolved opacities, no interstitial disease or bronchiectasis, has some scarring on L. (received Solumedrol IM x1, 22 days prior) CT sinus 3/13 with mild mucosal thickening of maxillary sinuses. Skin pricks: positive to pollens, dust mites and pets, most significant to grass and cat, dog, negative to mold. ENO < 20 ppb.

Summary. This 43 yo F S/p Treatment of pneumonia as inpatient for possible ‘community acquired Strep pneumonia’, however sputum culture grew Aspergillus fumigatus which was suspected as a possible contaminant. Has increasing eosinophilia that preceded this admission from 10-13 1800+ to post hospitalization in 2-13 of 4600+ with negative Aspergillus IgE but positive IgG to Aspergillus fumigatus, elevated total IgE 425. Differential of eosinophilia includes infection, ie parasitic or fungal, drug hypersensitivity, Churg Strauss, malignancy but being > 1500 eosinophils makes allergy and asthma unlikely etiologies, and pt denies travel out of the country or new meds. I’m considering starting immunotherapy and giving her Pneumovax once her respiratory symptoms are controlled.

Question: Any further workup for this pt with eosinophilia and pneumonia? I need to repeat her CBC in context of resolved pneumonia and waiting for enough time so no steroid effect on CBC since Solumedrol given 22 days ago. Does not seem like ABPA with negative IGE to molds on pricks, and neg on serology to A fumigatus that grew in sputum. No new medications (only on long standing Humera, Advair.) Malginancy is the only other possibility if eosinophils are still high. Can that level of eosinophilia occur from bacterial or fungal pneumonia?

A:

Thank you for your inquiry.

In pursuing a diagnosis in your patient, I would concentrate on the differential diagnosis of pulmonary infiltrates with eosinophilia.

This is a classical differential diagnosis in medicine, and there are excellent review articles which will help you organize a further evaluation. I have copied for you below two examples of these references; one by Michael Wechsler and the other by Bhatt and Allen.

In addition, we have several entries posted to our Ask the Expert website dealing with similar problems. You can access them by going to the Ask the Expert landing page and typing “eosinophilia, pneumonia” to pull up the majority of these and follow that by entering “Wechsler” into the search box for the remaining.

In essence, as noted, you would be pursuing the differential diagnosis of a patient presenting with pneumonia, hypereosinophilia, and asthma.

In your workup, you mentioned several possibilities. I think the most fruitful one for you to pursue immediately would be Churg-Strauss syndrome, and I would suggest that, in addition to pursuing the references and entries mentioned above, you go ahead and order, if it has not been done, antineutrophil cytoplasmic antibodies. The rationale for this test and the other tests that you might consider are found in the entries and references noted above.

Thank you again for your inquiry and we hope this response is helpful to you.

References:
1. Wechsler ME. Pulmonary eosinophilic syndromes. Immunol Allergy Clin North Am 2007 Aug; 27(3):477-92. Review.
2. Bhatt NY, Allen JN. Update on eosinophilic lung diseases. Semin Respir Crit Care Med. 2012 Oct;33(5):555-71. Epub 2012 Sep 21

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology