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Chronic Eosinophilic Pneumonia: a Pediatric Case Irene Rutigliano, MD1*, Sara Gorgoglione, MD2, Anna Pacilio, MD2, Carmela De Meco, MD1 and Michele Carmine Sacco, MD1

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Chronic Eosinophilic Pneumonia: a Pediatric Case Irene Rutigliano, MD1*, Sara Gorgoglione, MD2, Anna Pacilio, MD2, Carmela De Meco, MD1 and Michele Carmine Sacco, MD1 ISSN: 2378-3656 Rutigliano et al. Clin Med Rev Case Rep 2019, 6:264 DOI: 10.23937/2378-3656/1410264 Volume 6 | Issue 4 Clinical Medical Reviews Open Access and Case Reports CASe RePoRt Chronic Eosinophilic Pneumonia: A Pediatric Case Irene Rutigliano, MD1*, Sara Gorgoglione, MD2, Anna Pacilio, MD2, Carmela De Meco, MD1 and Michele Carmine Sacco, MD1 1Pediatrics, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy Check for 2Pediatrics, University of Foggia, Foggia, Italy updates *Corresponding author: Irene Rutigliano, Pediatrics, IRCCS Casa Sollievo della Sofferenza, Viale Padre Pio, San Giovanni Rotondo (FG), Italy, Tel: +393428088475; +390882416221, Fax: +390882416200 pulmonary infiltrates on chest imaging. These con- Abstract ditions are divided into two groups: Secondary forms Background: Eosinophilic lung diseases are a group of (such as allergic bronchopulmonary aspergillosi, bron- heterogeneous disorders characterized by blood eosino- philia and pulmonary infiltrates. These conditions are very chocentric granulomatosis, parasitic infection, drug rare in Pediatric sunset. reaction, eosinophilic vasculitis) and idiopathic forms Case report: A 12-year-old nonsmoking asthmatic girl (simple pulmonary eosinophilia, acute eosinophilic was admitted for general malaise and dry fatiguing cough. pneumonia [AEP], chronic eosinophilic pneumonia, id- Diagnostic course reveled marked hypereosinophilia and iopathic hypereosinophilic syndrome) (Table 1). chest radiography indicated multifocal and circumscribed bilateral pulmonary areas of consolidation. Bronchoscopy Chronic idiopathic eosinophilic pneumonia (ICEP), excluded the presence of neoplastic cells but marked or Carrington disease, is particularly rare in pediatric hypereosinophilia was found in bronchoalveolar lavage. population, characterized by pulmonary opacities The increased number of eosinophils in blood and in associated with tissue or peripheral eosinophilia and bronchoalveolar lavage, the radiological findings were suggestive of Chronic idiopathic eosinophilic pneumonia. respiratory symptoms lasting more than two weeks [1]. Conclusion: Chronic idiopathic eosinophilic pneumonia is a Here we report an unusual pneumonia presenta- rare disease, especially in Pediatrics. Often misdiagnosed, tion, antibiotic - resistant, in an Albanian teenager. the treatment is based on corticosteroid administration, but there is no consensus on the right management of the Case Report disease. A 12-year-old nonsmoking asthmatic girl was Keywords admitted to Hospital in other country, with a history Chronic eosinophilic pneumonia, Carrington disease, Chil- of ten days of cough, difficult breathing and asthenia. dren At admission, she had severe respiratory distress with Abbreviations/Acronyms chest wall retractions and 90% 2O -saturation in room ELD: Eosinophilic Lung Diseases; ICEP: Chronic Idiopathic air, needing oxygen supplementation. She also received Eosinophilic Pneumonia; AEP: Acute Eosinophilic Pneumo- inhaled corticosteroid and 2β agonist without any nia; CT: Chest Computed Tomography; BAL: Bronchoalve- improvement. olar Lavage Chest x-ray showed bilateral multiple thickening areas with mediastinal pleural involvement confirmed Background by CT scan. Pleural and bone marrow biopsy were per- Eosinophilic lung diseases (ELD), also known as Eo- formed in suspicion of malignancy, with negative re- sinophilic pneumonia, are a group of heterogeneous sponse. No clinical and radiological improvement were disorders with alveolar and/or blood eosinophilia and obtained during antibiotics and steroid treatment, for Citation: Rutigliano I, Gorgoglione S, Pacilio A, De Meco C, Sacco MC (2019) Chronic Eosinophilic Pneumonia: A Pediatric Case. Clin Med Rev Case Rep 6:264. doi.org/10.23937/2378-3656/1410264 Accepted: April 18, 2019: Published: April 20, 2019 Copyright: © 2019 Rutigliano I, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Rutigliano et al. Clin Med Rev Case Rep 2019, 6:264 • Page 1 of 4 • DOI: 10.23937/2378-3656/1410264 ISSN: 2378-3656 Table 1: Classification of the eosinophilic lung diseases. these reasons the patient was transferred to our Hos- Classification of the eosinophilic lung diseases pital. 1. Eosinophilic lung disease of undetermined cause At the admission in our Paediatric Division, she a) Solitary complained general malaise and dry fatiguing cough Idiopathic chronic eosinophlic pneumonia but her vital signs were normal (temperature 36.7 °C, Idiopathic acute eosinophlic pneumonia blood pressure 110/60 mmHg, pulse rate 87 bpm). Ox- b) Associated with systemic disease ygen-saturation in room air was 96% with respiratory Churg-Strauss Syndrome rate 20 per minute. Hypereosinophilic Syndromes Clinical evaluation revealed that her breathing 2. Eosinophilic Lung Disease of determined cause sounds were slightly decreased without crackles or a) Eosinophilic pneumonias of parasitic origin wheezing. Tropical eosinophilia Chest radiography indicated multifocal and circum- Ascaris pneumonia scribed bilateral pulmonary areas of consolidation with Larva migrans syndrome lamellar aspect and minimum thickening of pleural fis- Strongyloides stercoralis infection sure, confirmed by Lung ultrasound (Figure 1). Chest Eosinophilic pneumonias in other parasitic infectious Computed Tomography (CT) scan was performed, b) Eosinophilic pneumonias in other infectious causes showing multiple areas of parenchymal consolidation c) Allergic bronchopulmonary aspergillosis and related with many bronchiectasis stuffed of hypodense ma- syndromes terial and circumscribed ground glass opacity in the Allergic bronchopulmonary aspergillosis lower lungs (Figure 2). Complete Blood Count revealed Other allergic bronchopulmonary syndromes associated marked hypereosinophilia, confirmed by microscopic with fungi or yeasts peripheral blood examination (Eosinophil 37%, 3330/ Bronchocentric granulomatosis uL). Tuberculin skin test, Quantiferon-Gold-in-Tube d) Drug, toxic agents and radiation-induced eosinophilic and microbiological tests were all negative. Sweat test pneumonias showed normal values of chloride. Thus, we extended Drugs the investigation panel with tumour markers, levels of Toxic agents angiotensin converting enzyme and alpha-1antitrypsin Eosinophilic pneumonia induced by radiation therapy to the and immunological assays (Antinuclear antibody, An- breast tineutrophil cytoplasmic antibody, rheumatoid factor, 3. Miscellaneous lung diseases with possible C3, C4), all in normal laboratory range. IgE levels were associated esosinophilia high (459 Ku /l, normal value < 100) and skin prick tests Organizing pneumonia were positive for inhalant allergens (Dermatophagoides Asthma and eosinophilic bronchitis pteronyssinus and farinae, Graminaceae). The lympho- Idiopathic intestitial pneumonias cyte subsets instead showed a slight decrease of the Langherans cell granulomatosis normal CD4/CD8 T cells ratio (ratio 0.6). Erythrocyte Lung transplantation sedimentation rate was also elevated. No signs of car- Other lung diseases with occasional eosinophilia diac dysfunction were found at Electrocardiogram and Sarcoidosis Doppler echocardiography [2]. Paraneoplastic eosinophilic pneumonia Figure 1: Chest X-ray of the patient. Rutigliano et al. Clin Med Rev Case Rep 2019, 6:264 • Page 2 of 4 • DOI: 10.23937/2378-3656/1410264 ISSN: 2378-3656 Figure 2: CT scan of the chest in our patient. Table 2: Diagnostic Criteria for ICEP e IAEP. Inclusion criteria for ICEP based on adults series Inclusion criteria for IAEP based on adults series 1. Respiratory symptoms present > 2 weeks 1. Acute onset with febrile respiratory symptoms (< 1 month and especially < 7 days duration before medical examination) 2. Diffuse pulmonary alveolar consolidation with air 2. Bilateral diffuse infiltrates on imaging bronchogram and or ground glass opacities at chest imaging, especially with peripheral predominance 3. Eosinophil count in bronchoalveolar lavage fluid (BALF) > 3. PaO2 in room air < 60 mmHg, or PaO2/FiO2 < 300 mmHg, or 9 40% and/or peripheral blood eosinophilia > 1 × 10 cells/l oxygen saturation (SpO2) in room air < 90% 4. Absence of other causes of eosinophilic lung disease 4. Lung eosinophilia with > 25% eosinophils in BALF 5. Absence of determined cause of eosinophilic pneumonia - recent onset of tobacco smoking or exposure to inalhed dusts must be present Bronchoscopy excluded the presence of neoplastic years findings revealed the role of these cells and their cells but marked hypereosinophilia (38%) was found in granules in the pathogenesis of diseases. Actually, the bronchoalveolar lavage (BAL). There was no evidence of mechanisms of eosinophilic pathways is not complete- bacterial, fungal or mycobacterial infection in culture of ly known, but several interactions involving a complex BAL. The increased number of eosinophils in blood and network of cells, tissues, cytokines and chemokines in BAL, the radiological findings with the characteristic could explain systemic manifestations of eosinophilic ground glass pattern and the persistence of symptoms inflammation. Therefore, it is important to see at eosin- for about 4 weeks were suggestive of ICEP. Oral steroid ophilic syndromes as systemic disorders [6,7]. therapy was started (prednisone, 2 mg/kg/die for the The erythrocyte sedimentation rate in ICEP is usu- first 30
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