192 AN UNUSUAL RADIOGRAPHIC PRESENTATION OF IDIOPATHIC CHRONIC EOSINOPHILIC PNEUMONIA. (1st January 2005) - Hussain, S.
Abstract : Pulmonary eosinophilic diseases are a heterogeneous group of infiltrative lung diseases characterized by abnormally increased numbers of eosinophils within the lung parenchyma and sometimes blood eosinophilia. The typical radiographic finding is a photographic negative of pulmonary edema. We report a case with an unusual chest x-ray. A 48-year-old man with a history of mild chronic asthma for 8 years presented with progressively worsening shortness of breath and dry cough. He had no significant past medical history and was a lifetime non-smoker. On initial examination, he was oriented with no cyanosis or clubbing and was not in acute distress. He was afebrile with stable vitals and a respiratory rate of 18/min. Chest auscultation was significant for diffuse bilateral wheezing. Heart sounds were audible with no murmurs or gallop. No extremity edema, skin rashes or lymphadenopathy were noted. Laboratory values revealed a white cell count of 4.4 k/cmm (4.5-10.5 k/cmm) with normal hematocrit and platelets. Abnormally elevated eosinophil count of 28% (0-8%) was noted. Rest of the lab values were normal. Chest x-ray showed a slight fullness in the left suprahilar region and left upper lobe. CT scan of the chest confirmed a 2.3 × 1.6 cm irregular soft tissue mass in the medial left upper lobe. PET scan revealed an intense uptake in the left upper lobe lung lesion. Pulmonary function test showed a mild ventilator defect. A bronchoscopy with bronchoalveolar lavage showed neutrophilia with greater than 40% eosinophils. Transbronchial biopsy as well as CT guided FNAC of the left upper lung mass showed numerous tissue eosinophils with Charcot laden crystals. Later lab test showed an elevated IgE of 2362 IU/mL (0-158 IU/mL) but precipitin antibody test and the skin test for Aspergillus was negative. The specific IgG and IgE to Aspergillus was also negative. The sputum culture was negative for fungal, mycobacterial, and bacterial cultures. Four weeks of empiric prednisone therapy were initiated as patient refused an open lung biopsy. The lung mass disappeared and symptoms improved with the treatment. ICEP is a rare disorder with nonspecific symptoms. It is important to exclude other causes of eosinophilic pneumonias. Awareness of wide spectrum of clinical manifestation and prompt treatment would cure the symptoms and avoid unnecessary invasive tests and interventions.