Case summary – ICase summary – I

51 year old male

CC: Chest tightness and blood tinged sputum for 12 months

No fever, cough, dyspnea or weight changes

Ex-Smoker

PH: AR and sinusitis history, but no history of chronic asthma

X-ray Pleural effusion, Left 9 months ago

Pleural fluid: eosinophilia (21%), and exudate findings with high ADA level (65 U/L)

Lab: ELISA for PW/CS : positive, peripheral eosinophilia: 800/mm3

Imp: Tuberculous pleurisy and pulmonary paragonimiasis

Management: Ant-tbc medications and praziquantal for 3days

Follow up 1 month of anti-TB medicationFollow up 1 month of anti-TB medication

Still not resolved problemsStill not resolved problems

1. Wheezing developed

2. Persistent left pleural effusion

3. Peripheral eosinophilia: 3300/mm³ ( from 808)

4. Persistent blood tinged sputum, but normal BFS

5. Normal nerve conduction velocity

Imp) Churg-Strauss syndrome

Start oral prednisolone 30 mg/d, but not-well-controlled

After 6 month of anti-TB medication After 6 month of anti-TB medication

Pleural effusion: improved

Normalized blood eosinophil count-stopped steroid

Two months before the admission, recurred eosi

nophilia with increased pleural effusion developed

Case summary – II, problems on Case summary – II, problems on admissionadmission

Recurred blood eosinophilia & pleural effusion

No fever, crackle sound on chest

Peripheral eosinophilia: 1660/mm3, serum total IgE: 500 IU/ml

PFT: moderate obstruction pattern without bronchodilating response

Chest X-ray: left pleural effusion, Chest C-T: mass like lesion

The key findings of this patient..The key findings of this patient..

1. Persistent peripheral eosinophilia

2. Pleural effusion with eosinophilic infiltration

3. Airway obstruction findings including wheezy episode, reversible with steroid treatment history of allergic rhinitis, sinusitis and asthma

4. Mass like lesion

Diagnosis suggestedDiagnosis suggested

1. Pulmonary paragonimiasis : Based on recurrent blood tinged sp

utum, pleural effusion with mass like lesion, persistent eosinophi

lia , but no history of crayfish or crab history, high ADA level in

pleural fluid, failure to praziquantel treatment

2. Churg-Strauss syndrome : Commonly found asthma patients wit

h eosinophilia

3. Malignancy : Mass like lesion with pleural effusion in 51-yr old

male patient

4. TB granuloma : effusion, mass like lesion, high ADA level

Eosinophilia related diseasesEosinophilia related diseases

1. 1. Allergic diseasesAllergic diseases: severity related: severity related -asthma, AR, atopic dermatitis-asthma, AR, atopic dermatitis- ABPA- ABPA- Churg-Strauss syndrome- Churg-Strauss syndrome

2. 2. Parasite infectionsParasite infections: toxocara, An: toxocara, Ansakiasis, Paragonimiasissakiasis, Paragonimiasis

3. 3. DrugDrug induced induced

4. 4. Malignancy : Malignancy : lympho-proliferatilympho-proliferative diseasesve diseases

Paragonimiasis (1) Paragonimiasis (1)

• Caused by the lung fluke, the trematode of the genus Paragonimus

• Clinical symptoms depend on the location and developmental stage of worms.

• Cough (62-100%), Hemoptysis (61-95%), Chest pain (38-94%)

• Pleuritic chest pain, Pneumotherax caused by penetration of larvae through diaphragm/pleura

• Pleural effusions

typically eosinophilic with low glucose, low pH, and high LDH.

(CSS is the only other disease that produces this constellation of pleural fluid findings)

Paragonimiasis (2)Paragonimiasis (2)

• Radiologic findings

pulmonary nodule

pneumotherax

interstitial infiltrates

cavity formations

ring cysts resembling bronchiectasis

• Pleural effusion (48-62%) – most common finding

Parenchymal consolidation

• Treatment

Praziquantel 25mg/kg tid for 2 days is effective in > 90% of cases

Diagnostic criteria of CSSDiagnostic criteria of CSS

American College of Rheumatology (1990)

1. Asthma

2. Eosinophilia>10%, 1500 >

3. Neuropathy, mononeuropathy, or polyneuropathy

4. Pulmonary infiltrates

5. Paranasal sinus abnormality

6. Extravascular eosinophil infiltration on biopsy finding

Diagnosis when four of the six criteria are present

From J Allergy Clin Immunol 2001;108:s1-19

Typical case of CSSTypical case of CSS

1. Long standing asthma and rhino-sinusitis ( > 5 yrs) - uncontrolled cases requiring daily medications

2. Lung parenchymal infiltration

3. Evidence of vasculitis involving nerve, skin, reticulo-endoth

elial systems

4. Remission of eosinophilia after stopping oral corticosteroid i

s very rare

5. Remission of asthma symptoms without any medications is

very rare

Typical case of CSSTypical case of CSS

Lung cancerLung cancer

1. Pleural effusion

eosinophilia (>10%) is unusual in malignant effusion,

but, 20% of eosinophilic effusions malignant

20% of noneosinophilic effusions malignant

2. Peripheral eosinophilia

Eosinophilia occurs in patients who have lung cancer,

more frequently associated with Hodgkin’s disease

3. No systemic symptoms suggesting malignancy, long standing sy

mptoms, normal BFS and sputum result, PET finding– tissue bio

psy was done…

Chest 1996;110:1271-4

TB granulomaTB granuloma

1. No evidence of TB infection in sputum, pleural effusion and BFS

2. No eosinophils in pleural effusion or blood

3. Recurred pleural effusion after 6 months anti-TB medication

s

4. High ADA in pleural effusion

5. Positive PPD skin test

6. Positive Qunatiferon-TB GOLD test

Etiology known Parasite infestations (Tropical eosinophilia, Ascaris, Strongyloides stercoralis, others) Eosinophilic pneumonias of other infectious causes Allergic bronchopulmonary aspergillosis Drug, toxic agents, and radiation-induced eosinophilic pneumonias Eosinophilia-myalgia syndrome

Idiopathic Loeffler’s syndrome Acute eosinophilic pneumonia Chronic eosinophilic pneumonia Churg-Strauss syndrome Hypereosinophilic syndrome

Miscellaneous lung diseases with possible associated eosinophilia Organizing pneumonia Asthma and eosinophilic bronchitis Idiopathic interstitial pneumonias Langerhans cell granulomatosis Lung transplantation Other lung diseases with occasional eosinophilia Sarcoidosis Paraneoplastic eosinophilic pneumonia

Murray and Nadel’s Textbook of respiratory medicine, 4 th, 2005

Classifications of the Eosinophilic Lung DiseasesClassifications of the Eosinophilic Lung Diseases

ABPA : Asthma + eosinophiliaABPA : Asthma + eosinophilia

1. Long standing uncontrolled asthma

2. Sensitivity to Asp. fumigatus b

y skin test and high serum spec

ific IgE

3. High serum total IgE level

4. Central type bronchiectasis

5. Precipitating antibody, IgG to

Asp fumigatus

Acute and chronic eosinophilic pneumoniaAcute and chronic eosinophilic pneumonia

Drug induced, idiopathic, drug history, typical radiologic findings, Drug induced, idiopathic, drug history, typical radiologic findings, evidence tissue eosinophilia in BAL and sputumevidence tissue eosinophilia in BAL and sputum

ImpressionImpression

1. Pulmonary paragonimiasis

Persistent blood tinged sputum, pleural effusion, persistent

eosinophilia , granuloma formation

2. Malignancy, less likely