A rare case of acute eosinophilic pneumonia induced by vaping-associated lung injury: a case report.

BACKGROUND: Acute eosinophilic pneumonia (AEP) is well-known as one of the primary eosinophilic pulmonary diseases of unknown etiology. It's defined as a febrile illness along with acute onset respiratory failure that is commonly misdiagnosed at the initial presentation as infectious pneumonia. Despite the fact that AEP sometimes classified as idiopathic as no exact cause can be identified in most cases, it has been suggested recently to be linked with electronic cigarette or vaping products and associated with electronic cigarette or vaping associated lung injury (EVALI). Therefore, history of recent tobacco smoking or vaping exposure along with peripheral eosinophilia are crucial clinical findings suggestive of AEP. CASE PRESENTATION: A previously healthy 17-year-old female presented to the Emergency Room with one day history of progressively worsening shortness of breath accompanied by left sided pleuritic chest pain and fever. She wasn't taking any medications, denied traditional cigarette smoking, exposure to pulmonary irritants, recent travel and had no history of close contact with sick patient. She recently started vaping 20 days prior to the presentation. Initially, she was admitted with a presumptive diagnosis of atypical pneumonia but was found to have AEP due to a recent vaping exposure. CONCLUSION: Vaping is a well-known health hazard that has become a growing trend among adolescents and have been promoted as a safe and effective alternative to traditional cigarettes. The etiology of AEP remains unclear, but many studies suggest a possible link with recent tobacco smoking or vaping. A key challenge for this clinical entity is to reach the diagnosis after excluding all other pulmonary eosinophilia causes, and it has an excellent prognosis if diagnosed early and treated appropriately.

Vaping Associated Acute Eosinophilic Pneumonia: A Clinical and Radiologic Mimicker of COVID-19.

Acute eosinophilic pneumonia (AEP) is a rare cause of respiratory failure. It is primarily a disease of smokers, either a new smoker or an existing one with a recent increase in cigarette consumption. Other risk factors include toxic gas exposure, inhalational illicit drugs, and smoking marijuana. AEP has also been reported in patients with e-cigarette or vaping associated lung injury (EVALI). We present the case of a 20-year-old male who presented to the hospital with acute respiratory failure. The patient has been vaping heavily for the past three months and started smoking three days before presenting to the emergency department. He was hypertensive, tachycardic, tachypneic, and required high-flow nasal cannula to maintain SpO2 > 92%. His condition deteriorated in the first 24 hours following hospitalization requiring noninvasive positive pressure ventilation. Bronchoalveolar lavage revealed an eosinophil count of 36%. Bronchoalveolar lavage (BAL) cytology revealed lipid-laden macrophages. He was diagnosed with AEP due to EVALI, and the patient was treated with high dose corticosteroid with subsequent improvement. Before the bronchoscopic evaluation, the clinical and radiologic findings were consistent with COVID-19, and the patient was tested twice for SARS-CoV-2 PCR. In the appropriate clinical setting, AEP should be considered in the differential diagnoses of community-acquired pneumonia, acute respiratory distress syndrome (ARDS), and COVID-19, especially in this pandemic era.

Identification of Complex Pneumonia during the Outbreak of COVID-19: Bacterial Pneumonia Combined with Acute Eosinophilic Pneumonia in Patients with Maintenance Hemodialysis.

It is of crucial importance to diagnose patients in a timely and clear manner during the outbreak of COVID-19. Different causes of pneumonia makes it difficult to differentiate COVID-19 from others. Hemodialysis patients are a special group of people in this outbreak. We present a successfully treated case of a patient with maintenance hemodialysis from acute eosinophilic pneumonia for using meropenem when treating bacterial pneumonia, avoiding possible panic and waste of quarantine materials in dialysis centers.

Association between peripheral blood/bronchoalveolar lavage eosinophilia and significant oxygen requirements in patients with acute eosinophilic pneumonia.

BACKGROUND: We investigated the association between a combination of two markers, peripheral (PEC) and bronchoalveolar lavage (BAL) eosinophil percentage (BEP), and oxygen requirements in patients with acute eosinophilic pneumonia (AEP). METHODS: We retrospectively reviewed the medical records of patients with AEP treated at the Armed Forces Capital Hospital between May 2012 and May 2017. We used correlation analyses to assess the association between PEC/BEP and clinical outcomes in AEP patients. Receiver operating characteristic (ROC) curve analyses were used to calculate the cut-off value for BEP that categorised patients requiring a significant oxygen supply. The BAL/blood eosinophil (BBE) score was introduced to stratify patients with peripheral eosinophilia and elevated BEP. Clinical characteristics and outcomes were compared between the different groups. Multiple logistic regression was performed for significant oxygen requirements using two different models using age, C-reactive protein (CRP), smoking duration, and BBE score (model 1) and age, CRP, BEP, and PEC (model 2). RESULTS: Among the 338 patients, 99.7% were male, and their mean age was 20.4 ± 1.4 years. Only 0.6% of patients were never smokers and the mean number of smoking days was 26.2 ± 25.4. Correlation analyses revealed that both the PaO2/FiO2 ratio and duration of oxygen supply were associated with BEP. ROC curve analyses indicated a cut-off level of 41.5%. Patients with a high BBE score had favourable outcomes in terms of hypoxemia, hospital days, intensive care unit admission, oxygen supply days, and steroid treatment days. Multiple logistic regression revealed that BEP and BBE score tended to be associated with significant oxygen requirements. CONCLUSIONS: In this study, we revealed that both peripheral and BAL eosinophilia is associated with favourable outcomes in AEP patients.

Age distribution and seasonality in acute eosinophilic pneumonia: analysis using a national inpatient database.

BACKGROUND: Acute eosinophilic pneumonia (AEP) is a rare inflammatory lung disease. Previous studies have shown that most patients with AEP are aged 20 to 40 years, whereas several case studies have included older patients with AEP. These studies also suggested that AEP is more prevalent in summer, but they were limited due to their small sample sizes. We therefore investigated the age distribution and seasonality among patients with AEP using a national inpatient database. METHODS: Using the Japanese Diagnosis Procedure Combination database, we identified patients with a recorded diagnosis of AEP from 1 July 2010 to 31 March 2015. We examined patient characteristics and clinical practices including age, sex, seasonal variation, length of stay, use of corticosteroids, use of mechanical ventilation, and in-hospital mortality. RESULTS: During the 57-month study period, we identified 213 inpatients with AEP. The age distribution of AEP peaked twice: at 15 to 24 years and 65 to 79 years. The proportion of patients with AEP was highest in summer for those aged < 40 years, whereas it was distributed evenly throughout the year for those aged ≥ 40 years. The interval from hospital admission to corticosteroid administration and the duration of corticosteroid use were significantly longer in the older than younger age group. CONCLUSIONS: The age distribution of patients with AEP was bimodal, and seasonality was undetected in older patients. Older patients may be more likely to have delayed and prolonged treatment.

Eosinophilic pneumonia: A review of the previous literature, causes, diagnosis, and management.

Eosinophilic pneumonia (EP) is a rare disorder, comprising several heterogeneous diseases. Two major types of EP are acute eosinophilic pneumonia (AEP) and chronic eosinophilic pneumonia (CEP), both of which are characterized by marked accumulation of eosinophils in lung tissues and/or BAL fluid. AEP and CEP share some similarities in terms of pathophysiology, radiological findings, and treatment response to corticosteroids. However, they distinctly differ in etiology, clinical manifestations, and the nature of disease course. Especially, although AEP and CEP respond well to corticosteroids, relapse frequently occurs in patients with CEP, but rarely in those with AEP. Although CEP occasionally persists and becomes corticosteroid dependent, most patients with AEP completely recover. This article reviews previous studies and discusses the etiology, clinical manifestations, and treatment of AEP and CEP.

Pathologic features of smoking-related lung diseases, with emphasis on smoking-related interstitial fibrosis and a consideration of differential diagnoses.

Smoking-related interstitial fibrosis (SRIF) is frequently-seen and morphologically-distinctive finding in the lung tissue of cigarette smokers. It can be distinguished histologically from the idiopathic interstitial pneumonias and other causes of pulmonary interstitial fibrosis. SRIF is typified by dense thickening of the alveolar septa by thick collagen bundles with a hyalinized appearance, with the common admixture of bands of hyperplastic smooth muscle. Concomitant inflammation is minimal. SRIF predominates in the subpleural and centrilobular parenchyma, and is usually accompanied by the changes of centrilobular emphysema and respiratory bronchiolitis. Most patients with SRIF do not have clinical symptoms of the condition. This article reviews the pathologic features of SRIF and compares them with the appearances of other interstitial lung diseases, some of which are also related to cigarette smoking. Acute eosinophilic pneumonia is another lung disease that has an association with smoking, and its clinicopathologic features are considered here as well.

Eosinophilic pneumonia caused by daptomycin: Six cases from two institutions and a review of the literature.

Here we report six cases of daptomycin (DAP)-induced eosinophilic pneumonia (DIEP) encountered at two medical centers and present a review of 43 DIEP patients from 26 studies to compare the clinical characteristics and radiographic findings of acute and chronic eosinophilic pneumonia (AEP; CEP). Four of the six patients did not exhibit respiratory symptoms, and one patient with only fever was misdiagnosed with DAP-induced fever. According to our literature review and the present findings, male sex and old age were dominant risk factors for DIEP. Fever and fine crackles were the most common clinical manifestations. The DAP dose and duration of administration were not significant risk factors for DIEP, and we also could not find any association between allergic predisposition and DIEP. Among the reviewed patients, 51.8% did not show more than 25% eosinophils in bronchoalveolar lavage, which is a criterion for the diagnosis of drug-induced eosinophilic pneumonia. Chest images of all patients showed CEP patterns such as multiple reticulonodular infiltrates in the subpleural region and diffuse bilateral pulmonary infiltrates with ground-glass opacities. However, 66.7% of patients also exhibited pleural effusion, a feature specific to AEP. All patients showed prompt recovery after DAP withdrawal. Our results suggest that clinicians should consider DIEP as a differential diagnosis when patients receiving DAP therapy, particularly men and elderly patients, present with fever, even in the absence of respiratory symptoms. Furthermore, they should be aware that the occurrence of DIEP is independent of the DAP dose and administration duration, and allergic reaction.

The Rare Complication and Diagnostic Challenges of Pulmonary Eosinophilia in Graft versus Host Disease Patients after Hematopoietic Stem Cell Transplantation.

PURPOSE: Chronic graft versus host disease (cGvHD) is a common complication of hematopoietic stem cell transplantation (HSCT). Eosinophilic lung disease is a rare poorly understood complication in HSCT patients with cGvHD. These patients present similarly to those with Acute Eosinophilic Pneumonia (AEP). The purpose of this study is to better elucidate the presentation and potential treatment of this phenomenon. METHODS: We reviewed over 170 bronchoscopies in post-HSCT patients with respiratory symptoms. Of these, four patients, whose course was complicated by cGvHD, presented with respiratory symptoms, diffuse ground-glass opacities (GGO) on chest computerized tomography (CT), bronchoalveolar lavage (BAL) eosinophilia, and no evidence of infection. The clinical course of these patients was reviewed. RESULTS: Despite clinical presentation similar to AEP, not all patients had > 25% eosinophils on BAL, one criterion for AEP, however all improved with steroids. Steroid initiation was often delayed in favor of empiric antibiotics despite negative infectious workup. Several patients had recurrent episodes. Regarding possible associations, we examined but found no link between particular demographics, reason for HSCT, chemotherapy, immunosuppressants, or peripheral eosinophil count and pulmonary eosinophilia in these patients. GGO present on initial CT imaging became chronic in several of these patients. CONCLUSION: We propose that in post-HSCT patients with GvHD presenting with respiratory symptoms, GGO on CT, BAL eosinophilia of > 10%, and negative respiratory cultures, an autoimmune eosinophilic process may be occurring. Earlier recognition and initiation of corticosteroids in these patients may improve their outcomes as an autoimmune diagnosis was often delayed in favor of antibiotics.

Clinical implications of initial peripheral eosinophilia in acute eosinophilic pneumonia.

BACKGROUND AND OBJECTIVE: The initial peripheral eosinophil count (PEC) is rarely elevated but tends to increase during the clinical course of acute eosinophilic pneumonia (AEP). We evaluated whether initial peripheral eosinophilia is an indicator of mild disease in patients with AEP. METHODS: We retrospectively examined associations between initial peripheral absolute eosinophil count, inflammatory markers and clinical characteristics in 85 patients with AEP. RESULTS: Of 85 patients, 24 (28%) had initial peripheral eosinophilia (>500/µL). Initial peripheral absolute eosinophil count was inversely correlated to white blood cell (WBC) count (ρ = -0.386, P < 0.001), neutrophil percentage (ρ = -0.645, P < 0.001) and C-reactive protein (CRP; ρ = -0.495, P < 0.001). During treatment, peripheral absolute eosinophil counts increased, while inflammatory markers (WBC, neutrophil percentage, and CRP) decreased. Patients with initial peripheral eosinophilia had a longer duration from onset of symptoms to admission (P = 0.006), had lower WBC counts, neutrophil percentages and CRP values (all P < 0.001), and higher oxygen saturation (P = 0.004) than patients with normal peripheral eosinophil counts. Oxygen requirements (P = 0.013), duration of oxygen administration (P = 0.028) and intensive care unit admission rates (P = 0.003) were lower in patients with initial peripheral eosinophilia. All patients survived and recovered fully after corticosteroid or conservative treatment. CONCLUSIONS: Initial PEC may be related to a milder disease status on admission, compared with normal PEC in patients with AEP. This may help to stratify disease severity in AEP.

Diagnosis and Management of Daptomycin-Induced Acute Eosinophilic Pneumonia: A Case Report.

Daptomycin is a cyclic lipopeptide antibiotic that is indicated for the treatment of complicated skin infections and bacteremia caused by gram positive organisms. Acute eosinophilic pneumonia (AEP) is a rare, but serious adverse effect of daptomycin and caused by accumulation of eosinophils in the lung tissues, and can lead to respiratory failure. Early diagnosis and management of this condition is crucial to avoid severe complications, including death. Herein, we report a case of an elderly man who presented with signs and symptoms of AEP within two weeks of initiation of daptomycin for the treatment of MRSA bacteremia. The patient showed significant clinical improvement and decline in eosinophils upon discontinuation of daptomycin and starting a 5-day steroid course. Acute eosinophilic pneumonia should be kept in mind as a possible, although rare, adverse effect of daptomycin. Early recognition can be established through typical symptoms, eosinophilia, and chest X-ray showing pulmonary infiltrate. Rapid discontinuation of daptomycin with/without steroid therapy and supportive care usually results in significant clinical recover.

Rare Lung Malignancy Mimic: A Case of Daptomycin-Induced Acute Eosinophilic Pneumonia.

Daptomycin is an antibiotic used for resistant Gram-positive organisms and has the rare side effect of inducing acute eosinophilic pneumonia (AEP). This condition can be fatal due to respiratory failure if not treated, as eosinophils migrate to the lungs and inflammatory cascades cause epithelial injury. Daptomycin-induced AEP can be misdiagnosed as bacterial pneumonia or malignancy, which may lead to unnecessary testing or treatments. Diagnostic criteria include dyspnea, fever, recent daptomycin exposure, infiltrates on imaging, eosinophils on bronchoalveolar lavage or peripheral eosinophilia, and clinical improvement with medication discontinuation. We present a unique case of daptomycin-induced eosinophilic pneumonia in a 72-year-old male with the chief complaint of dyspnea and initial concerns for lung cancer after a spiculated nodule was seen on imaging. Prior to undergoing a lung biopsy, repeat imaging showed a decrease in the suspicious nodule, reducing the likelihood of malignancy and prompting a re-evaluation of the history of the present illness and medication list. Daptomycin was stopped, and the patient's symptoms and imaging improved. This case illustrates the importance of early recognition and appropriate treatment of AEP, which allows for complete clinical recovery.

A rare discovery of acute eosinophilic pneumonia associated with intensive cannabis use: Case report.

This article explores the case of acute eosinophilic pneumonia (AEP) linked to heavy cannabis inhalation, amidst the rising prevalence of cannabis use globally. AEP, characterized by eosinophilic pulmonary infiltration, poses unique challenges due to its unclear pathogenesis. This case study involves a 20-year-old with recent intense cannabis use, presenting with acute chest pain, cough, and dyspnea. Diagnostic evaluation revealed bilateral interstitial syndrome on thoracic imaging and elevated blood eosinophilia. Additional investigation through bronchoalveolar lavage confirmed the diagnosis of AEP. The patient's condition rapidly improved with glucocorticoids, highlighting the significance of prompt treatment. This article underscores the importance of raising awareness among clinicians of the possibility of AEP following cannabis exposure as a diagnosis to consider, as timely diagnosis and intervention are paramount in averting potentially fatal outcomes.

Acute and chronic eosinophilic pneumonia: an overview.

Acute and chronic eosinophilic pneumonia (AEP and CEP) include a group of rare interstitial lung diseases characterized by peripheral blood eosinophilia, increased eosinophils in bronchoalveolar lavage fluid, or eosinophilic infiltration of lung parenchyma. AEP is characterized by rapid onset, fast response to steroid treatment, and no relapse. CEP is characterized by marked tissue and peripheral blood eosinophilia, rapid response to steroid therapy, and tendency to disease recurrence. In addition, we briefly describe other eosinophilic lung diseases that must be considered in differential diagnosis of AEP and CEP. Eosinophilic pneumonias may be idiopathic or due to known causes such as medications or environmental exposure. At variance with previous reviews on this topic, a particular look in this overview was directed at pathological findings and radiological patterns.

Diffuse alveolar hemorrhage and acute eosinophilic pneumonia: A rare form of amiodarone pulmonary toxicity diagnosed by bronchoalveolar lavage.

A 56-year-old man presented with fever, cough, and bloody sputum. He had undergone mitral valve replacement with mechanical prosthesis 14 months prior for mitral valve disease. Subsequently, the patient was taking warfarin and amiodarone. Chest imaging revealed dense, infiltrative shadows, and blood tests showed prolonged prothrombin time and eosinophilia. Warfarin was withdrawn, and antibiotics were started, but bloody sputum and respiratory failure persisted. Considering that eosinophilia was observed after the administration of amiodarone, the drug was discontinued, and bronchoalveolar lavage was performed. Cytology showed foam cells, eosinophils, and hemosiderin-laden macrophages; amiodarone-induced diffuse alveolar hemorrhage (DAH) and acute eosinophilic pneumonia (AEP) were diagnosed, and the patient was treated with corticosteroids. This report describes the first documented case of amiodarone-induced DAH and AEP. When a patient taking amiodarone presents with antibiotic-refractory pneumonia with bloody sputum and eosinophilia, amiodarone-induced DAH and AEP should be considered. Learning objective: We report the first case of amiodarone-induced diffuse alveolar hemorrhage (DAH) and acute eosinophilic pneumonia (AEP) diagnosed by foam cells, eosinophils, and hemosiderin-laden macrophages on bronchoalveolar lavage cytology. When a patient taking amiodarone presents with antibiotic-refractory pneumonia with bloody sputum and eosinophilia, amiodarone-induced DAH and AEP should be considered.

An Unexpected Turn of Events in a Patient With Mitral Valve Endocarditis.

A variety of gram-positive infections can be treated with daptomycin. Daptomycin-induced acute eosinophilic pneumonia (DEP) is a rare adverse drug reaction with nonspecific clinical findings of dyspnea, dry cough, and fever. Although diagnostic criteria exist, prompt recognition is important to prevent rapid progression and respiratory failure. In this case, a 69-year-old female was initially admitted due to a prosthetic joint infection; however, her case was complicated by DEP.

Paraneoplastic acute eosinophilic pneumonia due to carotid angiosarcoma: A rare case.

Key Clinical Message: This case report emphasizes that we should analyze a patient's signs and symptoms as a whole rather than relying exclusively on a common pattern to diagnose the condition and indicates that thorough histological investigation and sample collection are needed to accurately diagnose this malignancy. Abstract: Angiosarcoma is a rare, fatal, and poorly understood malignant tumor of vascular endothelial cells which is a challenging disease to diagnose in the clinical settings and requires early diagnosis to achieve a favorable prognosis. Paraneoplastic syndromes associated with angiosarcoma can include hypercoagulability, thrombocytopenia, anemia, fever, weight loss, and night sweats. In some cases, the paraneoplastic syndrome can be the first sign of the underlying malignancy. Here, we present a 47-year-old individual with angiosarcoma over the right scapula accompanied by hemoptysis and other pulmonary complaints whom at first was thought to be metastatic polmunary involvement. However, the patient's dramatic response to corticosteroids, in addition to further imaging and paraclinical studies, led us to an acute eosinophilic pneumonia (AEP) diagnosis which is an eosinophilic infiltrations of alveolar spaces. The patient received chemotherapy for angiosarcoma and radiation, since the brachial nerve network was disrupted, leaving the tumor unresectable. After 3 years of continuous follow-up, the patient is now completely cured.

Cryptogenic Organizing Pneumonia and Idiopathic Eosinophilic Pneumonia: A Case Report of Clinically Identical Entities.

Cryptogenic organizing pneumonia (COP) and idiopathic eosinophilic pneumonia (IEP) are two forms of diffuse interstitial lung diseases (ILD) that lead to a rapid respiratory decline in young patients. Both conditions presented with similar clinical and radiological findings, making a clinical diagnosis challenging. They are both considered diagnoses of exclusion, and the treatment for both conditions is high-dose corticosteroids, leading to a quick recovery. Pathological specimens are often required prior to initiating appropriate treatment, leading to significant delays in appropriate therapy and a poorer prognosis. In this case report, we suggest that clinical pearls can be used to establish either diagnosis earlier, which leads to earlier treatment and better outcomes. Our patient presented with an acute respiratory distress syndrome (ARDS) picture, bilateral interstitial infiltrates with peripheral predominance, eosinophilia, and a negative initial infectious and cardiac workup. Based on these findings, we had a high initial suspicion that either COP or IEP was present. Our patient had a bronchoscopy done and was promptly started on steroid therapy soon after, which led to rapid clinical improvement. Pathological specimens were inconclusive, but the patient continued to improve, thereby confirming the presence of either form of ILD. The patient was subsequently discharged home with oxygen and recommended to follow up with a pulmonologist for further outpatient testing and management.

Smoking-Related Interstitial Lung Diseases.

Smoking-related interstitial lung diseases (ILDs) are a group of heterogeneous, diffuse pulmonary parenchymal disease processes associated with tobacco exposure. These disorders include pulmonary Langerhans cell histiocytosis, respiratory bronchiolitis-associated ILD, desquamative interstitial pneumonia, acute eosinophilic pneumonia, and combined pulmonary fibrosis and emphysema. This review summarizes the current evidence of pathogenesis, clinical manifestations, diagnostic approach, prognosis, and treatment modalities for these diseases. We also discuss the interstitial lung abnormalities incidentally detected in radiologic studies and smoking-related fibrosis identified on lung biopsies.