Q:

12/10/2011
A 35 yr old female with lund infiltrate, 3 foci, diagnosed as pneumonia 2 weeks before, presents with WBC 19000, 55% eosinophils. Patient had very good response to Predinisone and VFEND, clically and radiologically. What is your opinion about starting VFEND? (correct doses of above meds. given)

A:

Thank you for your inquiry.

You have a patient who has pulmonary infiltrates with eosinophilia (PIE syndrome). The differential diagnosis of PIE syndrome can be extensive and includes not only infections, but drugs, pulmonary eosinophilic pneumonia, allergic bronchopulmonary aspergillosis, primary vasculitis (Churg-Strauss) and many other conditions.

The first requirement is to make an etiologic diagnosis if at all possible. Of course, if the patient is acutely ill, treatment is necessary. However, I would not empirically start antifungal therapy unless there was evidence that a fungal infection was present. Antifungal drugs have been used in resistant cases of allergic bronchopulmonary aspergillosis , but you have not at this time made a diagnosis of either fungal infection or allergic bronchopulmonary aspergillosis.

As noted therefore, I would be reluctant to start antifungal therapy in the absence of a diagnosis of fungal involvement, but would first pursue the diagnosis based upon the differential diagnosis of PIE. There are a number of excellent reviews of this syndrome. I have copied abstracts of a few of these below, and also a link to a concise review which is available free of charge online.

My suggestion is, as noted, that studies directed at classifying the pneumonia and attempting to establish the diagnosis be done, and then specific therapy be instituted. If there is evidence of fungal involvement voriconazole or another antifungal agent can be considered at that time.

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

http://emedicine.medscape.com/article/301070-overview

Clin Rev Allergy Immunol. 2008 Jun;34(3):367-71.
Pulmonary eosinophilia.
Katz U, Shoenfeld Y.
Source
Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
Abstract
Eosinophils may infiltrate the lung tissue, thus impairing gas exchange and causing several symptoms as dyspnea, fever, and cough. This process may be secondary to several factors, including drugs or parasite migration, or primary (idiopathic). Acute eosinophilic pneumonia is life-threatening and presents frequently in young smokers as an acute hypoxemic respiratory failure of generally less than a week with bilateral lung infiltrates, frequently misdiagnosed as severe community-acquired pneumonia. This patients present without peripheral eosinophilia but usually have more than 25% eosinophils on bronchoalveolar fluid. Chronic eosinophilic pneumonia is a protracted disease of usually more than a month before presentation, with a predilection for middle aged asthmatic patients. Hypoxemia is mild-moderate, and there are usually more than 1,000 eosinophils/mm3 of peripheral blood. Bronchoalveolar fluid has high eosinophil levels (usually more than 25%). Migratory peripheral infiltrates are seen in the chest x-ray film. Both acute and chronic eosinophilic pneumonia are treated by glucocorticoids and respiratory support as well as avoidance of any recognized trigger

Semin Respir Crit Care Med. 2006 Apr;27(2):142-7.
Acute eosinophilic pneumonia.
Allen J.
Source
Department of Clinical Internal Medicine, Division of Pulmonary and Critical Care Medicine, Ohio State University, Columbus, Ohio 43205, USA.
Abstract
Acute eosinophilic pneumonia is a sudden and severe febrile illness that can result in life-threatening respiratory failure. Because this disease can mimic other diseases causing acute respiratory failure, the diagnosis may be missed or delayed. It is clinically distinguishable from other pulmonary eosinophilic diseases and can be diagnosed with bronchoalveolar lavage. Treatment with corticosteroids results in rapid reversal of respiratory failure and complete recovery, generally without relapse. In some patients, acute eosinophilic pneumonia may be caused by drugs, tobacco smoke, or other inhaled substances; however, in the majority of patients, the condition is idiopathic.

Curr Opin Pulm Med. 1996 Sep;2(5):380-9.
The pulmonary infiltration with eosinophilia syndrome.
Sharma OP, Bethlem EP.
Source
Division of Pulmonary and Critical Care Medicine, University of Southern California School of Medicine, Los Angeles 90033, USA.
Abstract
The term eosinophilia denotes an absolute eosinophil count above 500 cells/microL. Eosinophilia has been noted in various inflammatory disorders: skin conditions (eczema, dermatitis, generalized drug reactions), malignancies (Hodgkin's disease and lung cancer), chronic granulomatous disorders (tuberculosis, sarcoidosis), fungal diseases (coccidioidomycosis, aspergillosis), drug- and chemical--related conditions, and idiopathic pulmonary infiltrate and eosinophilia syndromes. The incidence of pulmonary infiltration with eosinophilia is on the rise. Idiopathic pulmonary eosinophilia should be distinguished from the eosinophilic myeloproliferative syndrome. The diagnosis can usually be secured with the help of a good history and physical examination enhanced by simple laboratory tests on blood and sputum and a chest radiogram. The therapy is then directed to correct the initial injury.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology