Diffuse lung infiltration in a homosexual man without AIDS

RICHARD POHIL, MD PHILIP MAPLE, MD GILBERT DALONZO, DO

Homosexual men who present Physical examination on admission revealed the pa- with respiratory complaints and diffuse tient to be well developed and healthy appearing. The lung infiltrates on chest x-ray generally oral temperature was 100F, and the respiratory rate have the AIDS syndrome and an ongoing was 22 breaths/min; otherwise, his vital signs were nor- opportunistic pneumonia. In the case mal. Bibasilar mid-to-end inspiratory crackles were presented, the usual diagnosis was not heard on auscultation. There was no evidence of ade- found and the patients lung infiltrates and nopathy, abdominal organ enlargement, or skin lesions, and the oral and rectal examinations had normal find- symptoms were due to drug-induced ings. eosinophilic pneumonia. This case report Diffuse, bilateral, interstitial-alveolar infiltrates were demonstrates that not all homosexual men demonstrated on the chest roentgenogram (Fig 1). The who present with the usual clinical picture electrocardiogram was normal. Values for arterial P02, for AIDS have AIDS and that not all diffuse PCO2, and pH were 60 mm Hg, 34 mm Hg, and 7.41, lung infiltrates are infectious in etiology. respectively. The peripheral leukocyte count was 12,000/ cu mm. The differential count included 66% eosinophils; the total eosinophil count was 80,000/cu mm. A homosexual man with diffuse pulmonary in- Based on presumptive diagnosis of Pneumocystis car- filtrates, cough, and hypoxemia usually is thought inii pneumonia, the patient initially was treated with to have acquired immunodeficiency syndrome an intravenous trimethoprim and sulfamethoxazole com- (AIDS). In such cases, the pulmonary infiltrates bination. The next morning, approximately 14 hours fol- are considered to be of infectious origin; Pneumocys- lowing admission, bronchoscopy, bronchoalveolar lavage, tis carinii, 1 cytomegalovirus, 2 and nontubercular and multiple transbronchial biopsy were performed un- mycobacterial infections3 generally are suspected. der fluoroscopic guidance. The case reported here demonstrates that not Histologic examination of the biopsy specimens re- all homosexual men who present with the classic vealed only marked eosinophilic infiltration (Fig 2). Bron- clinical picture have AIDS, and that not all diffuse choalveolar lavage failed to reveal an infectious etiol- ogy. Routine and special cultures for fungus, virus, lung infiltrates are infectious in etiology. Chla- mydia, Mycoplasma, Legionella, and Mycobacterium Report of case were negative. Stool specimens, as well as a duodenal aspirate, failed to demonstrate ova or parasites. There A 25-year-old homosexual man was admitted in August was no deficiency of helper T-lymphocytes, and the T- 1984 for evaluation of a productive cough with clear spu- cell helper/suppressor ratio in the peripheral blood was tum, bilateral pleuritic chest pain, and exertional dysp- normal. nea of two weeks duration. Following the fiberoptic bronchoscopy, antibiotic ther- Several days prior to the onset of these symptoms, a apy was discontinued, and steady improvement of both sore throat, coryza, and an oral ulceration were noticed clinical and laboratory parameters occurred. Subse- by the patient. Oral cephalosporin therapy was pre- quently, a chest film reflected clearing of the lung infil- scribed, but it was discontinued after a single dose when trates (Fig 3), and arterial blood gas values had normal- urticaria developed. Next, tetracycline (500 mg, four ized. Eight days after admission, immediately prior to times a day) was prescribed and taken for approximately discharge, the peripheral total eosinophil count decreased one week. All three symptoms improved in two to three to 1,000 cells/cu mm. days, but as they resolved, cough, chest pain, and dysp- At follow-up examination four months later, the pa- nea appeared and then worsened. The patient had rein- tients chest roentgenogram, arterial blood gas levels, stituted tetracycline therapy for approximately 48 hours and CBC (including peripheral smear) were normal. Two prior to hospital admission. years after discharge, he remained asymptomatic, and The medical history revealed that in March 1983, the serologic testing for human immunodeficiency virus was patient experienced an illness characterized by diarrhea, negative. weight loss of approximately 10 lb, and generalized mal- aise. Mild leukopenia and anemia also were present. Al- though definite diagnosis was not determined, the ill- Discussion ness resolved spontaneously. Since the recognition of AIDS in 1981, the disease

Diffuse lung infiltration in a homosexual man without AIDS 1115 Fig 2. Histologic specimen demonstrates marked eosinophilie in- filtration I H and E stain, original magnification, ,‹ 400).

The clinical presentation of our patient was strik- ingly similar to that of many patients with AIDS, that is, high-risk status, cough, dyspnea, fever, weight loss, hypoxemia, and bilateral lung infil- trates. There was no evidence of immunodeficiency or the presence of an opportunistic infection, but marked blood and lung eosinophilia was found.

Fig 1. Admission chest roentgenogram reveals bilateral intersti- This case presentation demonstrates that diffuse tial alveolar infiltrates. infiltrates in homosexual men are not necessarily due to infectious opportunistic pneumonia, and that the differential diagnosis must be expanded to in- clude other diseases. has maintained its position as one of the most fas- cinating, yet worrisome, topics in pulmonary medi- cine. According to the Centers for Disease Control, AIDS can be diagnosed when a high-risk patient with either Kaposis sarcoma or an opportunistic infection such as P carinii pneumonia is found to have serious underlying immunodeficiency.2-4 Other opportunistic infections include cytomega- lovirus, candidiasis, Cryptococcus neoformans, her- pes simplex and herpes zoster, mycobacterial in- fection, cryptosporidiosis, and toxoplasmosis. 5 Non- specific symptoms and signs, including fever, lym- phadenopathy, and weight loss, may or may not be present. Besides the two major risk groups of male ho- mosexuals or bisexuals and intravenous drug abus- ers, additional risk subgroups include hemophili- acs and other blood product transfusion recipients, as well as sexual partners and infants of high-risk group members.6 Immunologic abnormalities in AIDS include a selective deficit of helper T-lymphocytes, reversal of the T-cell helper/suppressor ratio in the periph- eral blood, elevated levels of serum immunoglobu- lin from polyclonal B-cell activation, and cutane- Fig 3. Chest film obtained eight days following admission shows ous anergy.3.4 marked clearing of bilateral lung infiltrates.

1116 September 1988 Journal of AOA/vol. 88/no.9 The list of diseases associated with bilateral lung 1.Jaffe 11W, Choi K, Thomas PA, et al: National case-control study of infiltrates and eosinophilia has grown substantially Kaposis sarcoma and Pneumocystis cariniipneumonia in homosexual men: Part I—epidemiological results. Ann Intern Med 1983;99:145-151. since the initial descriptions by Loff ler7 in 1932. 2. Mintz L, Drew WL, Miner RC, et al: Cytomegalovirus infections in Recently, Lynch and Flint8 categorized these di- homosexual men: An epidemiological study. Ann Intern Med 1983;99:326- eases into seven distinct syndromes: eosinophilic 329. 3. Murray JF, Felton CP, Garay SM, et al: Pulmonary complications pneumonia, chronic eosinophilic pneumonia, para- of the acquired immunodeficiency syndrome: Report of a National Heart, sitic eosinophilic pneumonia, allergic bronchopul- Lung, and Blood Institute Workshop. N Engi J Med 1984;310:1682- 1688. monary aspergillosis, bronchocentric granuloma- 4. Groopman JE: Kaposis sarcoma and other neoplasms. Ann Intern Med tosis, mucoid impaction of bronchi, and allergic 1983;99:208-210. 5. Update on acquired immune deficiency syndrome (AIDS)—United angiitis and granulomatosis. The clinical course States. MMWR 1982;31:507-514. and histologic characteristics of the lung biopsy al- 6. Chamberland ME, Castro KG, Haverkas HW, et al: Acquired immu- lowed us to classify our case as acute eosinophilic nodeficiency syndrome in the United States: An analysis of cases out- side high-incidence groups. Ann Intern Med 1984;101:617-623. pneumonia. 7. Loffler W: Zur Differential Diagnose der Lungenin Filtrierungen: III. Recently, this type of pneumonic process has Uber Fluchtige Succedan Infiltrate (mit Eosinophilie). Beitr Klin Tu- been linked with exposure to various drugs and berk 1932;79:368-392. 8. Lynch JP III, Flint A: Sorting out the pulmonary eosinophilic syn- chemical agents, including penicillin,9 nitrofuran- dromes. J Resp Dis 1984;5(July):61-78. toin,10 and tetracycline. 11,12 Although the exact eti- 9. Reichlin S, Loveless MH, Kane EJ: Loefflers syndrome following peni- ology of our patients disease process remains ques- cillin therapy. Ann Intern Med 1953;38:113-120. 10.Hailey FJ, Glascock HW Jr, Hewitt WF: Pleuropneumonic reactions tionable, the possibility of tetracycline causing the to nitrofurantoin. N Engl J Med 1969;281:1087-1090. eosinophilic process must be considered. 11.Ho D, Thshkin DP, Bein ME, et al: Pulmonary infiltrates with eosin- ophilia associated with tetracycline. Chest 1979;76:33-36. 12.Otero M, Goodpasture HC: Pulmonary infiltrates and eosinophilia Summary from minocycline, letter. JAMA 1983;250:2602. Diffuse lung infiltrates in a homosexual man gen- erally represent opportunistic infection; however, From the Department of Internal Medicine, Division of Pulmo- in the case presented this was not true. Obtaining nary Medicine, University of lbxas Medical School, Houston, a specific diagnosis is essential for the proper man- Thx. agement and treatment of patients who present Reprint requests to Dr DAlonzo, 5431 Fannin, Suite 1.274, Hous- with diffuse lung infiltrates. ton, TX 77030.

Diffuse lung infiltration in a homosexual man without AIDS 1117