Pulmonary Eosinophilia Treatment & Management
- Author: Jussi J Saukkonen, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
Give general supportive care by treating hypoxemia with supplemental oxygen. Treat bronchospasm with inhaled or nebulized bronchodilators. Inhaled corticosteroids may also be used when appropriate for persistent wheezing. Administer systemic steroids judiciously because they may worsen some infections.
- Extrinsic syndromes
- Medication-induced syndromes: These respond to the withdrawal of the offending agents, with few, if any, residual effects.
- Loeffler syndrome: Remove any potentially offending medications or ingested substances. Loeffler syndrome is mild and self-limited. Patients rarely require systemic corticosteroids.
- AEP: Patients with AEP respond rapidly to high doses of systemic corticosteroids and do not tend to relapse.
- Parasitic infections: Once a diagnosis of parasitic infection is established, initiate therapy with appropriate antibiotics. Patients who are immunocompromised or patients taking systemic steroids with strongyloidiasis may develop hyperinfection syndrome, often associated with gram-negative septicemia and adult respiratory distress syndrome. They may require empiric antibiotic coverage and respiratory and hemodynamic support.
- Fungal causes: For allergic bronchopulmonary aspergillosis (ABPA), administer systemic steroids and inhaled bronchodilators. Short-term itraconazole may be used in the treatment of ABPA, as data suggest that it causes reductions in inflammatory markers and may have steroid-sparing effects. For coccidioidomycosis, the use of steroids early in infection may result in dissemination and death.
- Intrinsic syndromes
- Chronic eosinophilic pneumonia (CEP): Patients with CEP respond rapidly to prednisone at a dose of 30-40 mg/d, with significant symptom improvement occurring within 48 hours and radiographic clearing occurring within 10 days. Relapse is common if steroids are discontinued in the first 6 months of therapy. Continue therapy with lower doses of prednisone for several additional months. Patients rarely require permanent steroid therapy.
- Idiopathic hypereosinophilic syndrome (IHES): Half the patients respond to corticosteroids, but others require more aggressive therapy with busulfan, cyclophosphamide, cyclosporin-A, etoposide, azathioprine, hydroxyurea, vincristine, or interferon alfa. Imatinib is used in myeloproliferative IHES.
- Churg-Strauss syndrome (CSS): Prednisone administered at a dose of 40-60 mg/d for several weeks, followed by lower-dose therapy for a total of 1 year, generally provides efficacious therapy. High doses of intravenous methylprednisolone, cyclophosphamide, and azathioprine have been used to treat patients whose conditions are refractory. In refractory cases, high-dose intravenous immunoglobulin has been reported to be helpful. Interferon-alpha and tumor necrosis factor inhibitors, such as infliximab and etanercept, have also been used.
- Eosinophilic granuloma (EG): Smoking cessation is essential. Corticosteroids are generally not beneficial.
Also see the following clinical guideline summaries:
Surgical intervention is rarely necessary for patients with these syndromes. The need for open lung biopsy is rare (see Procedures).
- Parasitic diseases
- Echinococcal cystectomy or lung resection is the preferred treatment for this disease. Right hepatic echinococcal cysts may be removed during the echinococcal cystectomy. Often, adjuvant medical therapy is administered.
- Dirofilariasis may be difficult to distinguish from malignancy and may require transthoracic needle aspiration or resection.
- Lung resection may be necessary if a solitary pulmonary nodule is present or if malignancy is in the forefront diagnostically.
- Mediastinoscopy may be necessary if lymphadenopathy, possibly representing lymphoma, is significant.
- Pneumothorax with obstructive lung disease
- This may require tube thoracostomy.
- If recurrent, such as with EG, pleurodesis may be required.
Often, the complexity of these patients' presentations and treatment warrants subspecialty consultation. This may facilitate diagnosis and treatment.
- Pulmonologists provide expertise in the diagnostic approach, optimize the management of respiratory symptoms, may perform flexible bronchoscopy when indicated, and assist in the long-term management of the disease.
- Infectious disease specialists provide diagnostic and therapeutic expertise and assistance, especially with unusual pathogens.
- Radiologists who have good knowledge of chest radiography and tomography findings can be invaluable. A radiologist may be needed in the rare instance that a radiologically guided biopsy is warranted.
- Consult a thoracic surgeon when an open lung biopsy is indicated.
- Consult a hematologist for management of IHES.
Patients who have ingested food, supplements, or medication to which the syndrome is attributed should subsequently avoid reexposure.
- Chemically related medications should be avoided.
- Measures should be taken to avoid ingestion of contaminated water or food.
- Patients should avoid incompletely cooked seafood and crustaceans.
- Patients should avoid incompletely cooked pork.
Discourage the patient from engaging in activities linked to the syndrome or encourage the patient to take measures to avoid recurrence of the syndrome.
- Patients should avoid contaminated water or soil known to harbor parasites or fungi.
- Patients should avoid close contact with animals known to harbor parasites until these animals have been decontaminated.
Sharma P, Sharma A, Vishwakarma AL, Agnihotri PK, Sharma S, Srivastava M. Host lung immunity is severely compromised during tropical pulmonary eosinophilia: role of lung eosinophils and macrophages. J Leukoc Biol. 2015 Oct 21. [Medline].
Bafadhel M, Saha S, Siva R, et al. Sputum IL-5 concentration is associated with a sputum eosinophilia and attenuated by corticosteroid therapy in COPD. Respiration. 2009. 78(3):256-62. [Medline]. [Full Text].
Gonlugur U, Gonlugur TE. Eosinophilic bronchitis without asthma. Int Arch Allergy Immunol. 2008. 147(1):1-5. [Medline].
Kawabata Y, Takemura T, Hebisawa A, et al. Eosinophilia in bronchoalveolar lavage fluid and architectural destruction are features of desquamative interstitial pneumonia. Histopathology. 2008 Jan. 52(2):194-202. [Medline].
Lee JH, Park HK, Heo J, et al. Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome induced by celecoxib and anti-tuberculosis drugs. J Korean Med Sci. 2008 Jun. 23(3):521-5. [Medline]. [Full Text].
Vijayan VK. Tropical pulmonary eosinophilia: pathogenesis, diagnosis and management. Curr Opin Pulm Med. 2007 Sep. 13(5):428-33. [Medline].
Swartz J, Stoller JK. Acute eosinophilic pneumonia complicating Coccidioides immitis pneumonia: a case report and literature review. Respiration. 2009. 77(1):102-6. [Medline].
Uchiyama H, Suda T, Nakamura Y, et al. Alterations in smoking habits are associated with acute eosinophilic pneumonia. Chest. 2008 May. 133(5):1174-80. [Medline].
Yoshimi M, Nannya Y, Watanabe T, et al. Acute eosinophilic pneumonia is a non-infectious lung complication after allogeneic hematopoietic stem cell transplantation. Int J Hematol. 2009 Mar. 89(2):244-8. [Medline].
Cottin V, Frognier R, Monnot H, Levy A, DeVuyst P, Cordier JF. Chronic eosinophilic pneumonia after radiation therapy for breast cancer. Eur Respir J. 2004 Jan. 23(1):9-13. [Medline].
Hartl D, Latzin P, Zissel G, Krane M, Krauss-Etschmann S, Griese M. Chemokines indicate allergic bronchopulmonary aspergillosis in patients with cystic fibrosis. Am J Respir Crit Care Med. 2006 Jun 15. 173(12):1370-6. [Medline].
Saito H, Tsurikisawa N, Tsuburai T, Akiyama K. Involvement of regulatory T cells in the pathogenesis of Churg-Strauss syndrome. Int Arch Allergy Immunol. 2008. 146 Suppl 1:73-6. [Medline].
Wechsler ME, Wong DA, Miller MK, Lawrence-Miyasaki L. Churg-strauss syndrome in patients treated with omalizumab. Chest. 2009 Aug. 136(2):507-18. [Medline].
Kumar R. Mild, moderate, and severe forms of allergic bronchopulmonary aspergillosis: a clinical and serologic evaluation. Chest. 2003 Sep. 124(3):890-2. [Medline].
Kaliterna DM, Perkovic D, Radic M. Churg-Strauss syndrome associated with montelukast therapy. J Asthma. 2009 Aug. 46(6):604-5. [Medline].
de Gorgolas M, Casado V, Renedo G, Alen JF, Fernandez Guerrero ML. Nodular lung schistosomiais lesions after chemotherapy for dysgerminoma. Am J Trop Med Hyg. 2009 Sep. 81(3):424-7. [Medline].
Velthove KJ, Bracke M, Souverein PC, et al. Identification of exacerbations in obstructive lung disease through biomarkers. Biomarkers. 2009 Sep 7. [Medline].
Hillas G, Loukides S, Kostikas K, Bakakos P. Biomarkers Obtained by Non-Invasive Methods in Patients with COPD: Where do we Stand, what do we Expect?. Curr Med Chem. 2009. 16(22):2824-38. [Medline].
Agarwal R, Gupta D, Aggarwal AN, Saxena AK, Chakrabarti A, Jindal SK. Clinical significance of hyperattenuating mucoid impaction in allergic bronchopulmonary aspergillosis: an analysis of 155 patients. Chest. 2007 Oct. 132(4):1183-90. [Medline].
Chung SY, Lee JH, Kim TH, et al. F-18 FDG PET scan findings in patients with Loeffler's syndrome. Clin Nucl Med. 2009 Sep. 34(9):570-5. [Medline].
Chu E, Whitlock WL, Dietrich RA. Pulmonary hyperinfection syndrome with Strongyloides stercoralis. Chest. 1990 Jun. 97(6):1475-7. [Medline].
Tsurikisawa N, Taniguchi M, Saito H, et al. Treatment of Churg-Strauss syndrome with high-dose intravenous immunoglobulin. Ann Allergy Asthma Immunol. 2004 Jan. 92(1):80-7. [Medline].
Hellmich B, Gross WL. Recent progress in the pharmacotherapy of Churg-Strauss syndrome. Expert Opin Pharmacother. 2004 Jan. 5(1):25-35. [Medline].
[Guideline] Dicpinigaitis PV. Chronic cough due to asthma: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan. 129(1 Suppl):75S-79S. [Medline].
[Guideline] Tarlo SM. Cough: occupational and environmental considerations: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan. 129(1 Suppl):186S-196S. [Medline].
Wark P. Pathogenesis of allergic bronchopulmonary aspergillosis and an evidence-based review of azoles in treatment. Respir Med. 2004 Oct. 98(10):915-23. [Medline].
Allen JN, Davis WB. Eosinophilic lung diseases. Am J Respir Crit Care Med. 1994 Nov. 150(5 Pt 1):1423-38. [Medline].
Allen JN, Pacht ER, Gadek JE, Davis WB. Acute eosinophilic pneumonia as a reversible cause of noninfectious respiratory failure. N Engl J Med. 1989 Aug 31. 321(9):569-74. [Medline].
Barrett-Connor E. Parasitic pulmonary disease. Am Rev Respir Dis. 1982 Sep. 126(3):558-63. [Medline].
Cordier JF. Eosinophilic pneumonias. Schwarz MI, King TE, eds. Interstitial Lung Disease. Hamilton, Ontario: BC Decker; 1998. 559-95.
Davis WB, Fells GA, Sun XH, Gadek JE, Venet A, Crystal RG. Eosinophil-mediated injury to lung parenchymal cells and interstitial matrix. A possible role for eosinophils in chronic inflammatory disorders of the lower respiratory tract. J Clin Invest. 1984 Jul. 74(1):269-78. [Medline]. [Full Text].
Fauci AS, Harley JB, Roberts WC, Ferrans VJ, Gralnick HR, Bjornson BH. NIH conference. The idiopathic hypereosinophilic syndrome. Clinical, pathophysiologic, and therapeutic considerations. Ann Intern Med. 1982 Jul. 97(1):78-92. [Medline].
Jederlinic PJ, Sicilian L, Gaensler EA. Chronic eosinophilic pneumonia. A report of 19 cases and a review of the literature. Medicine (Baltimore). 1988 May. 67(3):154-62. [Medline].
Lanham JG, Elkon KB, Pusey CD, Hughes GR. Systemic vasculitis with asthma and eosinophilia: a clinical approach to the Churg-Strauss syndrome. Medicine (Baltimore). 1984 Mar. 63(2):65-81. [Medline].
Naughton M, Fahy J, FitzGerald MX. Chronic eosinophilic pneumonia. A long-term follow-up of 12 patients. Chest. 1993 Jan. 103(1):162-5. [Medline].
Ottesen EA, Nutman TB. Tropical pulmonary eosinophilia. Annu Rev Med. 1992. 43:417-24. [Medline].
Peros-Golubicic T, Smojver-Jezek S. Hypereosinophilic syndrome: diagnosis and treatment. Curr Opin Pulm Med. 2007 Sep. 13(5):422-7. [Medline].
Pinkston P, Vijayan VK, Nutman TB, et al. Acute tropical pulmonary eosinophilia. Characterization of the lower respiratory tract inflammation and its response to therapy. J Clin Invest. 1987 Jul. 80(1):216-25. [Medline]. [Full Text].
Powers MA, Askin FB, Cresson DH. Pulmonary eosinophilic granuloma. 25-year follow-up. Am Rev Respir Dis. 1984 Mar. 129(3):503-7. [Medline].
Slavin RG, Hutcheson PS, Chauhan B, Bellone CJ. An overview of allergic bronchopulmonary aspergillosis with some new insights. Allergy Asthma Proc. 2004 Nov-Dec. 25(6):395-9. [Medline].
Sterk PJ, Hiemstra PS. Eosinophil progenitors in sputum: throwing out the baby with the bath water?. Am J Respir Crit Care Med. 2004 Mar 1. 169(5):549-50. [Medline].
Tillie-Leblond I, Tonnel AB. Allergic bronchopulmonary aspergillosis. Allergy. 2005 Aug. 60(8):1004-13. [Medline].
Wardlaw A, Geddes DM. Allergic bronchopulmonary aspergillosis: a review. J R Soc Med. 1992 Dec. 85(12):747-51. [Medline].
Weller PF. The immunobiology of eosinophils. N Engl J Med. 1991 Apr 18. 324(16):1110-8. [Medline].
Woolnough K, Wardlaw AJ. Eosinophilia in Pulmonary Disorders. Immunol Allergy Clin North Am. 2015 Aug. 35 (3):477-92. [Medline].