A CASE OF RECURRENT RESPIRATORY FAILURE AND EOSINOPHILIA CAUSED BY PAPILLARY RENAL CELL CARCINOMA

Abstract

<h3>Introduction</h3> Eosinophilia with end organ manifestations secondary to solid tumors is not well described. <h3>Case Description</h3> A 57-year-old female with Aspirin Exacerbated Respiratory Disease had well controlled asthma on aspirin 325mg twice daily and inhaled corticosteroid/long-acting beta-agonist. Suddenly, over 2 months, her asthma significantly worsened requiring 5 emergency room visits and 3 hospitalizations. When placed on high-dose systemic steroids, her respiratory symptoms improved and her absolute eosinophil count (AEC) on 60mg prednisone was 0.2 × 10³/mL. However, when prednisone was tapered below 30mg daily, she twice required emergent intubation for hypercapnic respiratory failure, and her AEC increased to 1.25 × 10³/mL. Respiratory failure was ultimately attributed to status asthmaticus. Extensive eosinophilia workup was negative except chest computed tomography which incidentally demonstrated a new calcified renal mass. The patient underwent nephrectomy, revealing type 2 papillary renal cell carcinoma (RCC). To avoid continued high-dose systemic steroids, mepolizumab was initiated. Post-nephrectomy and on mepolizumab, her asthma remained well-controlled, and her corticosteroids were tapered off. Now, four months post-nephrectomy, mepolizumab has been discontinued and her asthma remains well controlled with an AEC of 0.15 × 10³/mL. <h3>Discussion</h3> To our knowledge, this is the first case of type 2 papillary RCC associated with peripheral eosinophilia. In particular, we suspect her malignancy was associated with an eosinophilia that was not completely responsive to steroids, leading to recurrent severe asthma decompensation. This rare case highlights how sudden changes in asthma control should prompt evaluation as to new underlying triggers and that AEC should always be interpreted in the context of systemic steroid use.