Pulmonary Eosinophilia Treatment & Management

  • Author: Jussi J Saukkonen, MD; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Jan 18, 2012
 

Medical Care

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,[20] 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.[21] Interferon-alpha and tumor necrosis factor inhibitors, such as infliximab and etanercept, have also been used.[22]
    • Eosinophilic granuloma (EG): Smoking cessation is essential. Corticosteroids are generally not beneficial.

Also see the following clinical guideline summaries:

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Surgical Care

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.
  • Malignancy
    • 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.
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Consultations

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.
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Diet

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.
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Activity

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.
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Contributor Information and Disclosures
Author

Jussi J Saukkonen, MD  Associate Professor, Department of Internal Medicine, Division of Pulmonary/Critical Care Medicine, Boston University School of Medicine, Boston Medical Center

Jussi J Saukkonen, MD is a member of the following medical societies: American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Gregory Tino, MD  Director of Pulmonary Outpatient Practices, Associate Professor, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Medical Center and Hospital

Gregory Tino, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

References

  1. 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].

  2. Gonlugur U, Gonlugur TE. Eosinophilic bronchitis without asthma. Int Arch Allergy Immunol. 2008;147(1):1-5. [Medline].

  3. Kawabata Y, Takemura T, Hebisawa A, et al. Eosinophilia in bronchoalveolar lavage fluid and architectural destruction are features of desquamative interstitial pneumonia. Histopathology. Jan 2008;52(2):194-202. [Medline].

  4. 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. Jun 2008;23(3):521-5. [Medline].

  5. Vijayan VK. Tropical pulmonary eosinophilia: pathogenesis, diagnosis and management. Curr Opin Pulm Med. Sep 2007;13(5):428-33. [Medline].

  6. Swartz J, Stoller JK. Acute eosinophilic pneumonia complicating Coccidioides immitis pneumonia: a case report and literature review. Respiration. 2009;77(1):102-6. [Medline].

  7. Uchiyama H, Suda T, Nakamura Y, et al. Alterations in smoking habits are associated with acute eosinophilic pneumonia. Chest. May 2008;133(5):1174-80. [Medline].

  8. 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. Mar 2009;89(2):244-8. [Medline].

  9. Cottin V, Frognier R, Monnot H, Levy A, DeVuyst P, Cordier JF. Chronic eosinophilic pneumonia after radiation therapy for breast cancer. Eur Respir J. Jan 2004;23(1):9-13. [Medline].

  10. 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. Jun 15 2006;173(12):1370-6. [Medline].

  11. 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].

  12. Wechsler ME, Wong DA, Miller MK, Lawrence-Miyasaki L. Churg-strauss syndrome in patients treated with omalizumab. Chest. Aug 2009;136(2):507-18. [Medline].

  13. Kumar R. Mild, moderate, and severe forms of allergic bronchopulmonary aspergillosis: a clinical and serologic evaluation. Chest. Sep 2003;124(3):890-2. [Medline].

  14. Kaliterna DM, Perkovic D, Radic M. Churg-Strauss syndrome associated with montelukast therapy. J Asthma. Aug 2009;46(6):604-5. [Medline].

  15. 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. Sep 2009;81(3):424-7. [Medline].

  16. Velthove KJ, Bracke M, Souverein PC, et al. Identification of exacerbations in obstructive lung disease through biomarkers. Biomarkers. Sep 7 2009;[Medline].

  17. 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].

  18. 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. Oct 2007;132(4):1183-90. [Medline].

  19. Chung SY, Lee JH, Kim TH, et al. F-18 FDG PET scan findings in patients with Loeffler's syndrome. Clin Nucl Med. Sep 2009;34(9):570-5. [Medline].

  20. Chu E, Whitlock WL, Dietrich RA. Pulmonary hyperinfection syndrome with Strongyloides stercoralis. Chest. Jun 1990;97(6):1475-7. [Medline].

  21. Tsurikisawa N, Taniguchi M, Saito H, et al. Treatment of Churg-Strauss syndrome with high-dose intravenous immunoglobulin. Ann Allergy Asthma Immunol. Jan 2004;92(1):80-7. [Medline].

  22. Hellmich B, Gross WL. Recent progress in the pharmacotherapy of Churg-Strauss syndrome. Expert Opin Pharmacother. Jan 2004;5(1):25-35. [Medline].

  23. [Guideline] Dicpinigaitis PV. Chronic cough due to asthma: ACCP evidence-based clinical practice guidelines. Chest. Jan 2006;129(1 Suppl):75S-79S. [Medline].

  24. [Guideline] Tarlo SM. Cough: occupational and environmental considerations: ACCP evidence-based clinical practice guidelines. Chest. Jan 2006;129(1 Suppl):186S-196S. [Medline].

  25. Wark P. Pathogenesis of allergic bronchopulmonary aspergillosis and an evidence-based review of azoles in treatment. Respir Med. Oct 2004;98(10):915-23. [Medline].

  26. Allen JN, Davis WB. Eosinophilic lung diseases. Am J Respir Crit Care Med. Nov 1994;150(5 Pt 1):1423-38. [Medline].

  27. Allen JN, Pacht ER, Gadek JE, Davis WB. Acute eosinophilic pneumonia as a reversible cause of noninfectious respiratory failure. N Engl J Med. Aug 31 1989;321(9):569-74. [Medline].

  28. Barrett-Connor E. Parasitic pulmonary disease. Am Rev Respir Dis. Sep 1982;126(3):558-63. [Medline].

  29. Cordier JF. Eosinophilic pneumonias. In: Schwarz MI, King TE, eds. Interstitial Lung Disease. Hamilton, Ontario: BC Decker; 1998:559-95.

  30. 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. Jul 1984;74(1):269-78. [Medline].

  31. 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. Jul 1982;97(1):78-92. [Medline].

  32. Jederlinic PJ, Sicilian L, Gaensler EA. Chronic eosinophilic pneumonia. A report of 19 cases and a review of the literature. Medicine (Baltimore). May 1988;67(3):154-62. [Medline].

  33. Lanham JG, Elkon KB, Pusey CD, Hughes GR. Systemic vasculitis with asthma and eosinophilia: a clinical approach to the Churg-Strauss syndrome. Medicine (Baltimore). Mar 1984;63(2):65-81. [Medline].

  34. Naughton M, Fahy J, FitzGerald MX. Chronic eosinophilic pneumonia. A long-term follow-up of 12 patients. Chest. Jan 1993;103(1):162-5. [Medline].

  35. Ottesen EA, Nutman TB. Tropical pulmonary eosinophilia. Annu Rev Med. 1992;43:417-24. [Medline].

  36. Peros-Golubicic T, Smojver-Jezek S. Hypereosinophilic syndrome: diagnosis and treatment. Curr Opin Pulm Med. Sep 2007;13(5):422-7. [Medline].

  37. 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. Jul 1987;80(1):216-25. [Medline].

  38. Powers MA, Askin FB, Cresson DH. Pulmonary eosinophilic granuloma. 25-year follow-up. Am Rev Respir Dis. Mar 1984;129(3):503-7. [Medline].

  39. Slavin RG, Hutcheson PS, Chauhan B, Bellone CJ. An overview of allergic bronchopulmonary aspergillosis with some new insights. Allergy Asthma Proc. Nov-Dec 2004;25(6):395-9. [Medline].

  40. Sterk PJ, Hiemstra PS. Eosinophil progenitors in sputum: throwing out the baby with the bath water?. Am J Respir Crit Care Med. Mar 1 2004;169(5):549-50. [Medline].

  41. Tillie-Leblond I, Tonnel AB. Allergic bronchopulmonary aspergillosis. Allergy. Aug 2005;60(8):1004-13. [Medline].

  42. Wardlaw A, Geddes DM. Allergic bronchopulmonary aspergillosis: a review. J R Soc Med. Dec 1992;85(12):747-51. [Medline].

  43. Weller PF. The immunobiology of eosinophils. N Engl J Med. Apr 18 1991;324(16):1110-8. [Medline].

 
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