Acute Eosinophilic Pneumonia Induced by Varnish Particles

Practitioner's Corner 58

9. Løvik M, Namork E, Fæste C, Egaas E. The Norwegian National Reporting System and Register of Severe Allergic Reactions to Acute Eosinophilic Pneumonia Induced by Varnish Food. Norwegian J Epidemiol. 2004;14:155-60. Particles: A Diagnostic Challenge 10. Namork E, Fæste CK, Stensby BA, Egaas E, Løvik M. Severe allergic reactions to food in Norway: a ten year survey of cases Valentin S1, Ribeiro Baptista B1, Peretti L1, Koszutski M2 reported to the food allergy register. Int J Environ Res Public 1Département de Pneumologie, CHRU de Nancy, Vandœuvre- Health. 2011 Aug;8(8):3144-55. lès-Nancy, France 2Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, France

J Investig Allergol Clin Immunol 2019; Vol. 29(1): 58-60 doi: 10.18176/jiaci.0329 Manuscript received July 3, 2018; accepted for publication September 24, 2018. Key words: Eosinophilic lung disease. Environment. Eosinophils. Bronchoalveolar lavage. Stefanie Aurich Universitätsmedizin Leipzig Palabras clave: Enfermedad pulmonar eosinofílica. Ambiente. Eosinófilos. Klinik für Dermatologie, Venerologie und Allergologie Lavado broncoalveolar. Ph.-Rosenthal-Str. 23 04103 Leipzig E-mail: [email protected]

Acute eosinophilic pneumonia (AEP) is a rare disease of unknown cause. Unlike chronic idiopathic eosinophilic pneumonia, the disease mostly affects males with no history of asthma or allergies [1]. Several types of exposure, such as a recent change in tobacco consumption, are thought to be responsible for AEP [2]. Given that the clinical presentation of AEP is nonspecific (cough, fever, pleural effusion), the condition can often be mistaken for acute infectious pneumonia or acute respiratory distress syndrome (ARDS) [3]. The key investigation is bronchoalveolar lavage (BAL), which confirms AEP by revealing an eosinophilic cell pattern (>25% eosinophils) in the differential cell count of BAL fluid. We report a case of AEP induced by domestic exposure to varnish particles and illustrate the difficulty in diagnosing this condition correctly. A 57-year-old man with no medical history of interest presented to the emergency department with a 2-day history of chest pain, dry cough, and progressive dyspnea. He had no history of smoking, substance use, or allergy. He was in excellent physical condition and exercised every day. Ten days before his first respiratory symptoms, he had been exposed for several days to varnish particles without respiratory protection in a confined environment (wooden door maintenance). Twenty-four hours before admission, his family doctor had prescribed prednisone for flu-like syndrome. On examination in the emergency department, he was febrile with dyspnea at rest and oxygen saturation of 87% in ambient air. Auscultation revealed bilateral bronchial sounds with crackles. Thoracic computed tomography (CT) revealed interstitial syndrome (interlobular septal thickening) and bilateral ground-glass pattern with bilateral basal condensations. Biological tests revealed inflammatory syndrome. Kidney and liver function were normal. Intravenous cefotaxime and spiramycin were initiated for suspected atypical pneumonia. On the seventh day after admission, the patient was intubated for mechanical ventilation owing to hypoxemia. A second thoracic CT scan carried out on day 8 revealed worsening of the previous abnormalities

and a mild right pleural effusion (Figure). BAL revealed chemical component in the varnish was isocyanate, which has 2.7 × 105 cells/ mL with 75% neutrophils, 10% macrophages, been recognized for more than 60 years as a common cause and 0% eosinophils. Blood tests ruled out an autoimmune of sensitization leading to various pulmonary diseases such as cause, and microbiological samples were negative. Antibiotic occupational asthma. It should therefore be taken into account therapy was switched to piperacillin-tazobactam, and the when AEP is suspected. The other chemical compounds in severity of the patient’s condition (PaO2/FiO2 = 90) led to this case (alkyls) are unlikely to be involved in triggering 2 periods of prone positioning. eosinophilic lung diseases. The patient declined to undergo Because of the persistence of hypoxemia, a second allergy tests. The exact pathophysiology of AEP is unclear, BAL was performed on day 14 and revealed eosinophilic although hypersensitivity has been reported to be a possible alveolitis (6.9×105 cells/mL with 40% eosinophils). We mechanism, and the acute onset and striking response to started intravenous corticosteroids on day 14 (1.5 mg/kg/d corticosteroids clearly favor this mechanism [9]. The absence of methylprednisolone). The patient's health improved of an eosinophilic cell pattern in the first BAL fluid sample dramatically, enabling weaning from mechanical ventilation is unusual in AEP. Initially, BAL fluid showed a neutrophilic within 4 days and oxygen therapy before admission to cell pattern, as reported in cigarette-induced AEP [10]. It is the pulmonology department. Parenchymal opacities had therefore important to repeat BAL, in case severe hypoxemia completely disappeared after 5 days of corticosteroids. There is unresponsive to the conventional treatment of community- was no relapse during the follow-up period, and pulmonary acquired pneumonia or ARDS, in order not to miss the function test results were normal at discharge. differential diagnosis and, in particular, AEP. Several environmental triggers have been described in AEP Finally, we considered other etiologies of eosinophilic (exposure to smoke from fireworks [4] and dust after the attacks pneumonia in this case. Drug-induced AEP is unlikely in the on the World Trade Center [5]). However, as far as we know, light of the antibiotics timeline, even though some cases have this is the first report of AEP induced by domestic exposure been induced by other antibiotics [8]. Prompt recovery after to varnish particles. The diagnosis of AEP was confirmed by corticosteroids were started, with maintenance of antibiotics, eosinophilic alveolitis (40% eosinophils) in the second BAL and rules out this diagnosis. Moreover, there was no argument by the full recovery achieved with corticosteroids, as expected in favor of a parasitic disease, hematologic disease, or in AEP [6]. Peripheral eosinophilia was never observed, as hypereosinophilic syndrome. is often the case in AEP, which differs significantly from To conclude, we report a case of AEP induced by domestic chronic eosinophilic pneumonia [7]. This finding is important exposure to varnish particles containing isocyanate in a when ruling out drug-induced AEP, because all reported cases 57-year-old man with no medical history of interest. Diagnosis involve considerable peripheral eosinophilia [8]. Nevertheless, was made only after a second BAL. We emphasize the need it is important to note that the initial outpatient prescription to repeat BAL for differential cell count analysis in cases of of oral corticosteroids may explain the normal white blood severe hypoxemia that are refractory to conventional treatment. cell count. Exposure to varnish was confirmed by the patient AEP is similar to community-acquired pneumonia and ARDS himself, who reported 7 days of intense exposure in a confined in terms of clinical and radiological presentation, and the environment without respiratory protection. The time lapse eosinophilic cell pattern may be absent in some cases or at of 10 days between the first exposure and the first respiratory the initial stage of AEP, especially if the patient has received symptoms is consistent with this etiology. The main toxic corticosteroids.

Figure. Thoracic computed tomography scan on day 8 after admission to the intensive care unit revealing worsening of ground-glass opacities.

Funding Factors Affecting the Food Allergy Profile of The authors declare that no funding was received for the Children From Schools in Hortaleza District, present study. Madrid, Spain

Conflicts of Interest Cabrera M1, Ortiz-Menéndez JC2, Garzón B3 The authors declare that they have no conflicts of interest. 1Consulta de Alergia, Hospital los Madroños, Brunete (Madrid), Spain 2Departamento de Sanidad, Distrito de Hortaleza, Ayuntamiento References de Madrid, I’M FINE Research Group, Madrid, Spain 3Unidad de Estadística, Secretaría Adjunta de Informática, 1. Cottin V. Eosinophilic Lung Diseases. Clin Chest Med. Consejo Superior de Investigaciones Científicas (CSIC), Madrid, 2016;37(3):535-56. Spain 2. Brackel CLH, Ropers FG, Vermaas-Fricot SFN, Koens L, Willems LNA, Rikkers-Mutsaerts ERVM. Acute eosinophilic J Investig Allergol Clin Immunol 2019; Vol. 29(1): 60-62 pneumonia after recent start of smoking. Lancet Lond Engl. doi: 10.18176/jiaci.0330 2015;385(9973):1150. 3. Maia JM, Guedes F, Aragão I, Cardoso T. Eosinophilic Key words: Food allergy. School canteens. Anaphylaxis. Epinephrine. pneumonia presenting as life-threatening ARDS. BMJ Case Asthma. Polysensitization. Rep [Internet]. 2015. Palabras clave: Alergia a alimentos. Comedores escolares. Anafilaxia. 4. Hirai K, Yamazaki Y, Okada K, Furuta S, Kubo K. Acute Adrenalina. Asma. Polisensibilización. eosinophilic pneumonia associated with smoke from fireworks. Intern Med Tokyo Jpn. 2000;39(5):401-3. 5. Rom WN, Weiden M, Garcia R, Yie TA, Vathesatogkit P, Tse DB, et al. Acute eosinophilic pneumonia in a New York City firefighter exposed to World Trade Center dust. Am J Respir We previously reported the prevalence of food allergen– Crit Care Med. 2002;166(6):797-800. free diets in school canteens in the Hortaleza district of Madrid, 6. Rhee CK, Min KH, Yim NY, Lee JE, Lee NR, Chung MP, et al. Spain [1]. Given the increased frequency of childhood food Clinical characteristics and corticosteroid treatment of acute allergy, national and local policies have been developed to eosinophilic pneumonia. Eur Respir J. 2013;41(2):402-9. encourage school staff, families, and students to be aware 7. Buelow BJ, Kelly BT, Zafra HT, Kelly KJ. Absence of Peripheral of food allergy events. We have also described the use of Eosinophilia on Initial Clinical Presentation Does Not Rule Out epinephrine autoinjectors in this district [2]. the Diagnosis of Acute Eosinophilic Pneumonia. J Allergy Clin The aim of this study was to analyze the food allergy profile Immunol Pract. 2015;3(4):597-8. and factors influencing food allergy in children from schools 8. Hirai J, Hagihara M, Haranaga S, Kinjo T, Hashioka H, Kato in Hortaleza district, Madrid. H, et al. Eosinophilic pneumonia caused by daptomycin: Six A structured questionnaire on allergen-free diets based on cases from two institutions and a review of the literature. J a specialist report was administered in 49 schools in Hortaleza Infect Chemother Off J Jpn Soc Chemother. 2017;23(4):245- during the 2015-2016 school year (N=1121 children), after 9. a letter was sent to all families by the school principals 9. Badesch DB, King TE, Schwarz MI. Acute Eosinophilic insisting on the importance of drawing up an action plan for Pneumonia: A Hypersensitivity Phenomenon? Am Rev Respir children with food allergies. During the school year studied, Dis. 1989 Jan 1;139(1):249-52. 1069 students (95.4%) were served allergen-free diets. The 10. Shintani H, Fujimura M, Yasui M, Ueda K, Kameda S, Noto data recorded included sex, age, asthma history, type of school, M, et al. Acute eosinophilic pneumonia caused by cigarette presence or absence of polysensitization (sensitization to smoking. Intern Med Tokyo Jpn. 2000;39(1):66-8. 2 or more food groups), and epinephrine prescription. From these schools, 251 children (21.2%) had a food allergy action plan and 185 had been prescribed epinephrine (72.1% of all those with an action plan and 15.6% of those with a reported food allergy). Nine of the children with an autoinjector were under 3 years old, 60 were between 3 and 5 years old, Manuscript received May 18, 2018; accepted for publication September 25, 2018. 104 were aged between 6 and 14 years, and 12 were 15 years or older. For students without an action plan, only the type of Simon Valentin allergen-free diet they were on was noted. Frequencies were 1 bis rue du Morvan computed in February 2017. A Bonferroni correction was used 54500 Vandoeuvre-Lès-Nancy to account for multiple comparisons (multiple comparisons France of percentages). The relationship between food variables and E-mail: [email protected] epinephrine prescription were determined by cross-tabulation using a 2 test and Monte Carlo estimation of exact P values (SPSS, Version 24).