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Weekly Chest CasesImaging Conference Cases

Case No : 3

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  • Age/Sex 30 / M
  • Case Title C/C: productive cough and myalgia for 1 week. P/H: pulmonary tuberculosis (2 years ago), otitis media & allergic rhinitis for one year
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Diagnosis With Brief Discussion

Courtesy
C
Imaging Findings
There were patchy areas of peripheral consolidations in both lungs on chest radiograph.

High resolution CT revealed peripheral, non-segmental patchy consolidations in both lungs.
Discussion
Chronic eosinophilic pneumonia (CEP) is a rare disorder of unknown etiology characterized by striking systemic and pulmonary manifestations such as fever, cough, weight loss, malaise, shortness of breath, blood eosinophilia (nearly 90%), and a prompt response to corticosteroid therapy.

Symptoms are often severe and last several months.

Pathologically marked accumulation of eosinophil-rich exudate is evident in the alveolar spaces and often interstitium.


The chest radiograph displays peripheral non-segmental, homogeneous air space consolidation, often referred to as the negative of pulmonary edema.

This pattern can remain unchanged for weeks or months unless steroid therapy is given.

High resolution CT (HRCT) shows patchy air space consolidation, and most marked in the middle and upper lung zones(about 85%).


An appearance identical to that of CEP can be seen in patients with Loeffler's syndrome, which is, however, usually self-limited and associated with pulmonary infiltrates that are transient or "fleeting". That is, areas of consolidation with Loeffler's syndrome can appear and disappear within days; CEP has a more protracted course, and areas of consolidation remain unchanged course over weeks or months.

The presence of peripheral air space consolidation can only be considered suggestive of CEP, which have a predominantly upper lobe distribution, in the appropriate clinical setting.

An identical appearance of peripheral air space consolidation can be seen in bronchiolitis obliterans with organizing pneumonia (BOOP). However, the consolidation in BOOP/COP often involves the lower-lung zones to a greater degree. On the other hand, some patients with lung disease have pathologic features of both CEP and BOOP.


The disease often develops in middle life from the third to seventh decades. The patients may be atopic (50%), asthmatic (40%), and have allergic rhinitis and nasal polyps (5-10%). The disease occasionally remits spontaneously, however, steroid therapy is usually required.

Rapid clearing is usually seen within a few days, considerable resolution in about a week and complete clearing by 1 month.

The long term prognosis for patients with CEP is excellent but the majority will require long term low dose oral corticosteroid therapy in order to prevent relapse.
Reference
1. Webb WR, Muller NL, Naidich DP. HRCT of the lung. Raven Press; New York, 1992; 91-93
2. Ebara H, Ikezoe J, Johkoh T, et al. Chronic eosinophilic pneumonia: Evaluation of chest radiograms and CT features. JCAT 1994; 18: 738-744
3. Gaensler EA, Carrinton CB. Peripheral opacities in chronic eosinophilic pneumonia: the photographic nogative of pulmonary edema. AJR 1977; 128: 1-13
4. Naughton M, Fahy J, FitzGerald MX. Chronic eosinophilic pneumonia: A long-term follow-up of 12 patients. Chest 1993 Jan; 103(1): 162-5
Keywords
Lung, Eosinophilic lung disease, CEP,
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