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Eosinophilic Lung Disease: a Clinical Overview

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Eosinophilic Lung Disease: a Clinical Overview Focus on CME at the University of British Columbia Eosinophilic Lung Disease: A Clinical Overview The eosinophilic lung diseases are a diverse group of pulmonary disorders ranging from the trivial to the potentially fatal. Accurate diagnosis is essen- tial, since effective treatment is available in most cases. By Frank Ryan MB, FRCPI, FRCPC, FCCP Presented at the 2nd Annual University of British Columbia Respiratory and Critical Care Update, Whistler, British Columbia, March 2001. he eosinophilic lung diseases are a heteroge- peripheral blood. More specifically, eosinophilic T neous group of pulmonary disorders charac- infiltration of the lungs (with or without periph- terized by an increase in circulating and tissue eral eosinophilia) is established by identifying eosinophils. Pulmonary eosinophilia can be an excess of eosinophils, either in bronchoalve- defined generally as pulmonary infiltrates on radi- olar lavage fluid obtained at bronchoscopy, or by ological imaging together with an increase in the open lung biopsy. Pathologically, there may be absolute number of eosinophils (> 250/µL) in the involvement of the airways, lung parenchyma, or both. Dr. Ryan is associate professor of Unfortunately, eosinophil biology and the medicine, University of British pathophysiology of eosinophilic lung diseases Columbia, and active staff, divi- are poorly understood.1 Eosinophils are a type of sion of respiratory medicine, granulocyte derived from the bone marrow. Vancouver Hospital and Health Distinguishing morphologic features include a Sciences Centre. His special bi-lobed nucleus and specific granules that con- interests include sleep-disordered tain a distinctive electron-dense crystalloid core breathing and clinical aspects of composed of major basic protein (Figure 1). The infiltrative lung disease. eosinophil plays a role in the host defenses The Canadian Journal of CME / December 2001 53 Eosinophilic Lung Disease Summary Eosinophilic Lung Disease: A Clinical Overview • The eosinophilic lung diseases are a heterogeneous group of pulmonary disorders characterized by an increase in circulating and tissue eosinophils. Pulmonary eosinophilia can be defined generally as pulmonary infiltrates on radiological imaging together with an increase in the absolute number of eosinophils (> 250/µL) in the peripheral blood. • Often, the first clue to the presence of eosinophilic lung disease is the incidental finding of an elevated peripheral eosinophil count on routine testing in a patient presenting with respiratory symptoms. • Most patients have an elevated peripheral eosinophil count, with the exception of those with some drug reactions and the early stages of acute eosinophilic pneumonia. Abnormalities on the chest radiograph are present in most cases of eosinophilic lung disease. • Normally, bronchoalveolar lavage (BAL) fluid contains < 1% eosinophils. Up to 20% eosinophils is a non-specific finding that can be seen in a variety of interstitial lung diseases. Greater than 20% eosinophils in the BAL fluid is seen in acute and chronic eosinophilic pneumonia, Churg-Strauss syndrome, idiopathic hypereosinophilic syndrome, parasitic infestations and drug reactions. against helminthic parasites and in allergic reac- will be outlined based on information obtained tions. Activated eosinophils, under the direction from a focused patient history and physical of helper T-lymphocytes, can release a variety of examination, supplemented by appropriate labo- cytokines and inflammatory mediators that ratory investigations. Each condition will then cause injury to various body tissues, including be discussed briefly. the lungs. The causes of excess eosinophil pro- duction and tissue infiltration are unclear, but Differential Diagnosis abnormal clonal proliferation of T-lymphocytes, resulting in excess production of eosinophilopoi- History. Often, the first clue to the presence of etic cytokines, is one possibility. eosinophilic lung disease is the incidental finding In the absence of a clear understanding of of an elevated peripheral eosinophil count on rou- eosinophil function, it is not possible to develop tine testing in a patient presenting with respiratory a classification of eosinophilic lung diseases symptoms. The chronicity of the symptoms and based on pathophysiologic principles. A variety the peripheral eosinophilia are important elements of clinical classifications, therefore, have been of the diagnosis, since transient eosinophilia is suggested.2-4 This article is based on one such usually of no consequence. Common respiratory classification proposed by Allen and Davis in symptoms include cough, wheeze, chest tightness which 10 categories of eosinophilic lung disease and dyspnea. Less commonly, patients may devel- are described (Table 1).5 First, an approach to op hemoptysis, chest pain or expectoration of differentiating among these various conditions tenacious mucus plugs. A chronic unproductive 54 The Canadian Journal of CME / December 2001 Eosinophilic Lung Disease Table 1 Classification of Eosinophilic Lung Diseases Simple pulmonary eosinophilia Chronic eosinophilic pneumonia Acute eosinophilic pneumonia Churg-Strauss syndrome Idiopathic hypereosinophilic syndrome Asthma Figure 1. An electron micrograph of the interior of an Allergic bronchopulmonary aspergillosis eosinophil showing the characteristic bi-lobed nucleus and cytoplasmic granules containing rhomboid, electron- Bronchocentric granulomatosis dense crystalloid cores. Parasitic infections Drug reactions cough, particularly at night, in the appropriate clinical setting, should suggest the possibility of eosinophilic lung disease. A history of asthma or Table 2 atopy should be sought routinely, since several Eosinophilic Lung Diseases causes of eosinophilic lung disease occur in Associated With Asthma patients with this background (Table 2). Upper respiratory tract symptoms, including rhino- Asthma sinusitis and nasal polyposis, are prominent in Allergic bronchopulmonary aspergillosis Churg-Strauss syndrome. Constitutional symp- toms, such as fever, weight loss, malaise, night Bronchocentric granulomatosis sweats and anorexia are prominent presenting fea- Chronic eosinophilic pneumonia tures of chronic eosinophilic pneumonia, Churg- Churg-Strauss syndrome Strauss syndrome, idiopathic hypereosinophilic syndrome and certain cases of parasitic infestation and allergic drug reactions. system involvement. Physicians should pay partic- Obtaining a patient’s thorough travel history is ular attention to symptoms of cardiovascular, skin, essential in identifying parasitic infestations con- neurologic, gastrointestinal (GI), musculoskeletal tracted in countries where these are endemic or renal involvement. Finally, eosinophilia occa- (Table 3). A careful drug history also is required sionally can occur in association with interstitial and should include details of over-the-counter lung disease, lung cancer and fungal infections. remedies and illicit drug use (Table 4). Some caus- Physical examination. Several causes of es of eosinophilic lung disease, particularly eosinophilic lung disease may have signs of air- Churg-Strauss syndrome and idiopathic hypere- flow obstruction (Table 2), such as overinflation, osinophilic syndrome, are characterized by multi- hyperresonance and wheezing. Rhinitis and nasal The Canadian Journal of CME / December 2001 55 Eosinophilic Lung Disease Table 3 Table 4 Parasitic Infections Frequently Examples of Drugs Causing Encountered in North America Eosinophilic Lung Disease Strongyloides stercoralis Nitrofurantoin Ascaris lumbricoides Phenytoin Toxocara Sulfasalazine Ancylostoma Ampicillin Echinococcus Minocycline Methotrexate Trichinella spiralis L-tryptophan Inhaled heroin or crack cocaine polyposis can occur in atopic asthma and Churg- Strauss syndrome. Signs of consolidation or crack- Inhaled pentamidine les, indicating pulmonary parenchymal or intersti- tial involvement, may occur in cases of chronic several parasites, including Toxocara, Ancylostoma, and acute eosinophilic pneumonia, Churg-Strauss Trichinella and Paragonimus. The test also may syndrome, parasitic infestations, or result from miss the intestinal stage of Ascaris and drug reactions. Dermatological manifestations Strongyloides. A variety of serological tests useful may include palpable purpura in Churg-Strauss in making the differential diagnosis of syndrome, urticaria or angioedema in the idio- eosinophilic lung disease are listed in Table 5. pathic hypereosinophilic syndrome, or the serpig- Pulmonary function tests may aid in the differen- inous rash of cutaneous larva migrans tial diagnosis, although they are mainly helpful in (Ankylostoma brasiliense). Multi-system involve- following the course of the disease and the ment, including cardiac disease, strongly suggests response to treatment. Churg-Strauss syndrome or idiopathic hypere- Imaging. Abnormalities on the chest radi- osinophilic syndrome, with systemic thrombo- ograph are present in most cases of eosinophilic emboli being a particular feature of the latter. lung disease. This is not the case, however, for Investigations. Most patients have an elevated idiopathic hypereosinophilic syndrome where peripheral eosinophil count, with the exception of abnormalities occur in less than 25% of patients, those with some drug reactions and the early and in patients with asthma where abnormalities stages of acute eosinophilic pneumonia. Profound are uncommon. Characteristic appearances in the eosinophilia (> 10,000/µL) can occur in idiopath-
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