A Case of Acute Eosinophilic Pneumonia Following Tdap Vaccine

Introduction: Acute eosinophilic pneumonia (AEP) is an uncommon lung disease. Its incidence and epidemiology remain understudied till date. The hypothesized etiology of AEP is an acute hypersensitivity reaction to an inhaled antigen such as tobacco smoke and other peculiar environmental factors. Vaccines as triggers of AEP, albeit very rare, have been reported in the literature. Case presentation: A 64-year-old male with history of hyperlipidemia on atorvastatin presented to the emergency room with complaints of cough productive of pink tinged sputum, exertional shortness of breath, chills and fever with maximum recorded temperature of 101 °F. His symptoms started within a few hours of receiving tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine two days ago. He denied any recent travel. He was a lifelong non-smoker and was employed as hospital case manager. His vitals were significant for tachycardia 116/min, tachypnea 30 breaths/min and SaO2 of 93 % on 10L. On physical examination, he was noted to have coarse and diminished breath sounds in both lung fields. Initial lab work showed elevated leukocyte count of 20.4 k/uL with absolute eosinophil count of 1.6 k/uL. Other labs were unremarkable. Diffuse bilateral reticulonodular and alveolar opacities were visualized on chest X-ray. Computed tomography (CT) of the chest showed profuse pulmonary nodules, scattered ground glass opacities and septal thickening concerning for bilateral multifocal pneumonia (figure 1). Blood cultures and sputum cultures were obtained and he was empirically treated with ceftriaxone and azithromycin. Sputum eosinophil smear was positive raising concerns for fungal and parasitic infections. Cultures remained negative and his hypoxia worsened. Thus, infectious diseases and pulmonology were consulted. Extensive infective disease work-up for bacterial, fungal, parasitic and viral pathogens came back negative. CT guided biopsy of a lung nodule demonstrated interalveolar eosinophil and fibrin deposition consistent with eosinophilic pneumonia (figure 2). Patient was started on glucocorticoids with dramatic improvement in his symptoms, imaging and oxygen needs. With his symptom onset following Tdap vaccine and negative infective work-up, AEP was suspected to be triggered by the vaccine. Discussion: AEP provoked by vaccination is rare. Cases have been reported with influenza, pneumococcal and also COVID-19 vaccines. To the best of our knowledge, this is the first report of AEP following Tdap vaccine in adults. Only up to 30% of patients with AEP will have peripheral eosinophilia. Diagnosis is usually confirmed on lung biopsy and patients respond very well to glucocorticoids.

Vaping, is it a safer alternative then smoking?

Introduction: The use of Electric cigarettes has been gaining popularity, especially in teenagers. The CDC has reported 2668 cases of electronic cigarette use and vaping associated lung injury (EVALI) as of 14 January 2020. Youth Tobacco survey of 2018 shows 20.8% of high school students had tried vaping in the past 30 days. Case presentation: 22-year-old female presented to the emergency department with fevers, night sweats, fatigue, shortness of breath, dry cough, loss of weight and appetite for 2 weeks. She also reported nausea, vomiting, diarrhea with occasional bright red blood per rectum for 5 days. She had been smoking e-cigarettes for 2 years. Vitals were significant only for tachycardia. Physical examination was unremarkable. Significant labs included hemoglobin 12.4 g/dL, platelets 509 k/uL, ferritin 458 ng/ml, ESR 111 mm/hr, CRP 312.3 mg/L, LDH 308 U/L, procalcitonin 0.16 ng/ml and D-Dimer 2.19 μg/ml. Chest X-Ray showed bibasilar reticulonodular opacities. Computed Tomography angiography of the chest was negative for pulmonary embolism but demonstrated diffuse small patchy reticulonodular airspace opacities throughout both lungs with “tree-in-bud” appearance and subpleural sparing (image). Ceftriaxone and doxycycline were initiated for suspected community acquired pneumonia. SARS COV-2 PCR and IgG, comprehensive respiratory panel, acid fast bacilli cultures, Quantiferon TB, aspergillus, coccidioides, histoplasma, blastomycosis, urine strep/legionella antigens, ANA, ANCAs, blood and sputum cultures, comprehensive enteric panel were all negative. However, she did test positive for mycoplasma IgG and IgM. Ultrasound abdomen was unremarkable. Bronchial washings cytology on bronchoscopy demonstrated lipid laden macrophages confirmed by Oil-red stain-O. Given elevated inflammatory markers, history of e-cigarette use, radiological and cytological findings, Pulmonology conceded that her symptoms were consistent with E-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI). Ceftriaxone was discontinued. Steroids were initiated along with doxycycline for co-infection with mycoplasma. Her symptoms improved remarkably after therapy. Discussion: EVALI usually has symptom onset within 90 days of vaping with pulmonary infiltrates in the absence of infection or other causes of respiratory failure. Symptoms include pulmonary, gastrointestinal and constitutional. EVALI is more likely to occur with vaping of tetrahydrocannabinol (THC) containing products. No specific diagnostic tests for EVALI have been noted, but bronchoalveolar lavage washings exhibiting lipid-laden macrophages with oil red O stain are common. CT scan findings with bilateral diffuse, ground glass opacities with subpleural sparring are commonly associated with EVALI. Vitamin E Acetate in THC compounds have been implicated as the cause of injury. Treatment involves steroids and vaping cessation.