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SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Acute eosinophilic pneumonia is a rare illness characterized by eosinophilic infiltration of the lung parenchyma. Cases often present with fever, severe dyspnea, bilateral infiltrates, and eosinophilia on BAL exams. The cause of eosinophilic pneumonia is unknown, but is thought to be related to inhalational exposure of an irritant or toxin. Most cases are responsive to steroid treatment. This case demonstrates acute eosinophilic pneumonia in a patient who recently recovered from COVID-19 pneumonia. CASE PRESENTATION: A 50 year old female with a history of multiple sclerosis, seizure disorder secondary to MS, Irritable Bowel Syndrome, and a distant history of tobacco smoking and opiate dependence on chronic suboxone therapy, presented with dyspnea secondary to respiratory failure. The patient was urged to present by her husband after findings of hypoxia to 79% on room air with cyanosis of the lips and fingers. She recently recovered from COVID-19 1 month prior, at which time she had symptoms of cough productive of red mucus, fever, and exhaustion;but states she never returned to her baseline. With ongoing hypoxia, the patient was intubated for mechanical ventilation. Subsequent bronchoscopy with BAL resulted in a elevated eosinophil count to 76%, with fungal elements and PCR positive for HSV-1. The patient was initiated on high dose glucocorticoid therapy in addition to Acyclovir and Voriconazole. A CT with IV contrast revealed extensive bilateral pulmonary emboli involving the segmental and subsegmental branches throughout both lungs and extension into the right pulmonary artery;the patient was started on anticoagulation. Shortly after beginning glucocorticoid therapy, the patient had significant improvement and was able to be weaned off ventilation to simple nasal cannula. She was able to be safely discharged home with two liters of supplemental oxygen and steroid taper. DISCUSSION: Acute Eosinophilic pneumonia is a rare condition with an unknown acute disease process. The diagnostic criteria for acute eosinophilic pneumonia includes: a duration of febrile illness less than one month, hypoxia with an SpO2 <90%, diffuse pulmonary opacities, and otherwise absence of inciting causes of pulmonary eosinophilia (including asthma, atopic disease, or infection). Diagnosis of eosinophilic pneumonia is attained after meeting clinical criteria with a BAL sample demonstrating an eosinophilia differential of >25%. The mainstay of treatment for this condition is glucocorticoid therapy with most cases resolving rapidly after treatment. CONCLUSIONS: Fewer than 200 cases of acute eosinophilic pneumonia have been reported in medical literature. It is imperative to keep a wide differential as critical illness may be rapidly improved with appropriate therapy. The cause of acute eosinophilic pneumonia is largely unknown, it is unclear what role COVID-19 may have played in the development of this pneumonia. Reference #1: Allen J. Acute eosinophilic pneumonia. Semin Respir Crit Care Med. 2006 Apr;27(2):142-7. doi: 10.1055/s-2006-939517. PMID: 16612765. Reference #2: Nakagome K, Nagata M. Possible Mechanisms of Eosinophil Accumulation in Eosinophilic Pneumonia. Biomolecules. 2020 Apr 21;10(4):638. doi: 10.3390/biom10040638. PMID: 32326200;PMCID: PMC7226607. Reference #3: Yuzo Suzuki, Takafumi Suda, Eosinophilic pneumonia: A review of the previous literature, causes, diagnosis, and management, Allergology International, Volume 68, Issue 4, 2019, Pages 413-419, ISSN 1323-8930 DISCLOSURES: No relevant relationships by Tayler Acton No relevant relationships by Calli Bertschy No relevant relationships by Stewart Caskey No relevant relationships by Shekhar Ghamande No relevant relationships by Tyler Houston No relevant relationships by Zenia Sattar No relevant relationships by Heather Villarreal
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SESSION TITLE: Critical Diffuse Lung Disease Cases 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Acute eosinophilic pneumonia (AEP) is dramatic in presentation mimicking infectious pneumonia or acute respiratory distress syndrome in previously healthy individuals. Medications are a commonly recognized cause of AEP. Daptomycin, has been strongly linked to AEP. Herein, we present a case of a patient with a septic joint treated with Daptomycin who went on to develop AEP. CASE PRESENTATION: Patient is an 80 year old man with history of hypertension, hypothyroidism, atrial flutter, complete heart block status post pacemaker, who had a hx of a mucinous cyst on his left index finger, requiring hospitalization. Blood cultures were positive for MRSA s/p debridement of the joint. He was discharged on 4 weeks of intravenous daptomycin. Two weeks after being discharged he presented back to the hospital with fevers, fatigue and worsening shortness of breath. His temperature was 103.8 and O2 saturation of 90% on 2L NC. Laboratory findings included WBC count of 8.6 with no eosinophilia on differential, ESR 110, negative blood cultures, sputum cultures with commensal flora, negative urine legionella, PCR for SARS COV-2 was negative. Chest radiograph showed mild interstitial airspace disease in the left mid and lower thorax, along with small bilateral pleural effusions. CT chest showed scattered bilateral consolidations and ground glass opacities and trace bilateral effusions. Daptomycin was switched to Vancomycin. Patients oxygen requirements had increased to 6l NC. Patient underwent airway exam with bronchoscopy and broncheoalveolar lavage in superior segment of the lingula, which showed inflamed bronchial mucosa with copious secretions. Cell count of the BAL showed increased eosinophil count with negative gram stain and culture. Patient was started on methylprednisolone 60 mg four times per day and then tapered. Vancomycin was switched to oral linezolid. Patient's hypoxia improved and was discharged home on 3l NC. At four week follow up, he no longer required oxygen on ambulation and chest radiograph showed complete resolution of infiltrates. DISCUSSION: Over 140 drugs have been recognized as a cause of drug induced eosinophilic pneumonia (DIEP). The diagnosis of DIEP requires febrile illness <5 days, diffuse bilateral infiltrates, hypoxemia and BAL showing 25% eosinophils or eosinophilic pneumonitis on lung biopsy. Additionally, a diagnosis of DIEP requires exposure to a candidate drug in the appropriate time frame, exclusion of infectious causes of eosinophilic pulmonary opacities. It also requires clinical improvement after cessation of medication. Daptomycin has been strongly linked to DIEP. In 2010 US FDA issued a warning about the risk of developing eosinophilic pneumonia during treatment with Daptomycin. CONCLUSIONS: Daptomycin is strongly linked with DIEP. Clinicians should maintain a high index of suspicion for DIEP in patient treated with daptomycin who develop respiratory distress. Reference #1: Uppal, P., LaPlante, K.L., Gaitanis, M.M. et al. Daptomycin-induced eosinophilic pneumonia - a systematic review. Antimicrob Resist Infect Control 5, 55 (2016). https://doi.org/10.1186/s13756-016-0158-8 Reference #2: Cottin V. Eosinophilic Lung Diseases. Clin Chest Med. 2016 Sep;37(3):535-56. doi: 10.1016/j.ccm.2016.04.015. Epub 2016 Jun 25. PMID: 27514599. Reference #3: Rosenberg CE, Khoury P. Approach to Eosinophilia Presenting With Pulmonary Symptoms. Chest. 2021 Feb;159(2):507-516. doi: 10.1016/j.chest.2020.09.247. Epub 2020 Sep 28. PMID: 33002503;PMCID: PMC8039005. DISCLOSURES: No relevant relationships by Kamelia Albujoq No relevant relationships by Rajaninder Sharma
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Introduction Eosinophilic pneumonia is a class of lung diseases characterized by accumulation of eosinophils in the lung. Chronic eosinophilic pneumonia (CEP) is diagnosed through radiographic imaging and bronchoalveolar lavage (BAL) with elevated eosinophil count (>25%) in the setting of pulmonary symptoms for more than 2 weeks. While CEP is often an idiopathic disease, it may also be caused by medications, illicit substances, or infections. Identifying the trigger is imperative for successful treatment. A 71-year-old man presented with fever and chronic shortness of breath that started after COVID-19 infection (6 months prior to presentation). Medical history was also significant for multiple myeloma, asthma, hypertension, type 2 diabetes, coronary artery disease, chronic kidney disease, and Alzheimer's dementia. Current medications included bortezomib, pomalidomide, aspirin, clopidogrel , donepezil, tramadol and insulin. Lenalidomide was discontinued 3 months prior due to generalized skin rash and high peripheral eosinophilia (19%). On presentation, physical exam revealed mild respiratory distress, bibasilar crackles, and bilateral pedal edema. Long COVID Syndrome was suspected. He was started on antibiotics and diuretics with no improvement. Labs revealed mild peripheral eosinophilia. Chest X-ray showed diffuse bilateral reticular nodular opacities predominantly on the right. CT chest revealed reticulonodular infiltrates in both lungs predominantly in the right upper lobe with small pleural effusion. Bronchoscopy with BAL was negative for infection but revealed 28% eosinophils. Pomalidomide was discontinued and oral prednisone started. Discussion: CEP is part of a group of eosinophilic lung diseases characterized by abnormal accumulation of eosinophils in the lung tissue. Symptoms include dyspnea and cough in the majority of cases, but may also include fever, sinusitis, rhinitis, fatigue and weight loss. The radiographic hallmarks are bilateral alveolar infiltrates peripherally predominantly in the upper lobes and may be ground glass or consolidation. The presence of an elevated eosinophil count (>25%) in a BAL confirms the diagnosis. Though often idiopathic, identification of possible causes is important for proper management. In our case, the patient has multiple risk factors including possible Long COVID Syndrome and malignancy. Medications such as bortezomib, lenalinomide and pomalidomide have been known to cause diffuse lung injury. To the best of our knowledge there is one case report illustrating Lenalinomide related CEP. History of asthma is present in most cases of idiopathic CEP. Our patient had multiple potential triggers for CEP. We suspect that CEP was medication-related in this case. (Figure Presented).