AN UNUSUAL CASE OF ACUTE EOSINOPHILIC PNEUMONIA IN OLD AGE

ABSTRACT

TOPIC Allergy and Airway TYPE Medical Student/Resident Case Reports INTRODUCTION: Acute eosinophilic pneumonia/pneumonitis (AEP) is a rare respiratory illness characterized by eosinophil accumulation in the pulmonary interstitium and airspaces.Due to limited research done in older population, there is delayed and underdiagnosis in patients above age 40.Here we present a unique case of a 96-year-old man with AEP. CASE PRESENTATION A 96-year-old lifetime non-smoker male with a history of hypertension, DVT on therapeutic enoxaparin presented to the hospital from a nursing home with a productive cough and increasing shortness of breath.He was found to be saturating at 80% on 4 liters of oxygen. Patient had a fever of 100.1F.Physical exam was significant for bilateral diminished breath sounds.His chest x-ray revealed worsening bilateral pulmonary infiltrates since his last admission with pneumonia last month.He was started on empiric antibiotics and High flow oxygen.CT chest showed bilateral ground glass opacities with increased interstitial thickening.Blood cultures, respiratory pathogen panel, SARS-COV2 PCR were negative. The patient's eosinophils increased to 11.7% with a progressive decline in neutrophil count. The bronchoalveolar lavage showed presence of numerous clumps of eosinophils. Patient was diagnosed with AEP and started on methylprednisolone 80 mg twice daily. Antibiotics were stopped and patient's status improved with continuous steroid treatment. Patient improved and was discharged on steroid taper. DISCUSSION: AEP is an idiopathic entity commonly associated with smoking, medications, allergic diathesis and parasitic infections. Furthermore, individuals between 20-40 years of age are most commonly affected. It causes IL-5 release and eosinophils accumulation, resulting in the release of toxic proteins and lipid mediators that promote a pro inflammatory reaction. Eosinophil counts may be normal on presentation, as seen in this case. Symptomatic AEP resembles pneumonia and While diagnosing AEP, it is important to exclude other disorders such as asthma or other atopic illnesses as these also respond to corticosteroids. Gold standard diagnosis of AEP is bronchoscopy with BAL which reveals eosinophilia (>25%). Treatment of AEP requires eliminating the inciting factor and initiating corticosteroids. While there are no clear guidelines on the optimal dosing of corticosteroids, there is evidence to suggest that high-dose IV steroids is effective in patients requiring mechanical intubation, whereas low dose oral prednisone is efficient in patients with minimal hypoxia. CONCLUSIONS: Our case here is unique as it highlights the occurrence of AEP in old age in the absence of associated factors. It is prudent to be vigilant of leukocyte trends in patients with recent history of pneumonia as not to misdiagnose and to consider other possible etiologies, such as AEP.If identified and treated appropriately, the disease has favorable outcomes with no long term sequalae. REFERENCE #1 Rhee CK, Min KH, Yim NY, Lee JE, Lee NR, Chung MP, Jeon K. Clinical characteristics and corticosteroid treatment of acute eosinophilic pneumonia. Eur Respir J. 2013 Feb;41(2)402-9. doi 10.1183/09031936.00221811. Epub 2012 May 17. PMID 22599359. REFERENCE #2 Pope-Harman, Amy L.;Davis, Bruce W.;Allen, Elizabeth D.;Christoforidis, John A.;Allen, James N. Acute Eosinophilic Pneumonia A Summary of 15 Cases and Review of the Literature, Medicine November 1996 - Volume 75 - Issue 6 - p 334-342 DISCLOSURES No relevant relationships by MohammadAsim Amjad, source=Web Response No relevant relationships by Ajinkya Buradkar, source=Web Response No relevant relationships by Kashyap Kela, source=Web Response No relevant relationships by Pooja Kharbanda, source=Web Response No relevant relationships by jacob miller, source=Web Response No relevant relationships by Princy Shah, source=Web Response