Eosinophilic Alveolitis?

Abstract

To the Editor:We agree with Davis and co-workers that there are therapeutic implications of eosinophilic bronchoalveolar lavage (BAL).1Davis BW Wilson HE Wall RL Eosinophilic alveolitis in acute respiratory failure.Chest. 1986; 90: 7-9Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar We recently evaluated a 69-year-old white woman with a nonproductive cough of four weeks' duration. She was a nonsmoker and took no medications. She had no history suggesting atopy, asthma or any hypersensitivity pneumonitis. Physical examination was remarkable for tachypnea at rest and bilateral diffuse rales. Cardiac examination results were unremarkable. Her CBC showed no eosinophilia. Arterial blood gas levels (FIo2 21 percent) showed Po2 of 49 and Pco2 of 25. Screening spirometry demonstrated FVC 1.05 (47 percent) and FEV1 .98 (50 percent). Chest roentgenographic film revealed bilateral lower lobe infiltrates (Fig 1).After nondiagnostic sputum evaluation, she was empirically started on intravenous erythromycin therapy. Progressive respiratory failure requiring mechanical ventilatory support rapidly ensued (four days). Bronchoscopy with BAL and transbronchial biopsy (TBBx) was performed. This lung biopsy revealed a lymphocytic interstitial infiltrate without eosinophilia. Special stains were negative for infectious organisms, but BAL fluid demonstrated 30 percent eosinophils. She was treated with intravenous methylprednisolone and was extubated within 48 hrs. At three months, pulmonary function tests showed normal volumes and flows with a normal chest roentgenographic film.Davis1Davis BW Wilson HE Wall RL Eosinophilic alveolitis in acute respiratory failure.Chest. 1986; 90: 7-9Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar did not comment on the course of steroid therapy in his two cases. Our patient was tapered over four months from an initial oral dose of prednisone 50 mg daily. Two months later she relapsed with identical roentgenographic and clinical findings. Bronchoscopy with BAL again showed eosinophilia (25 percent) in lavage fluid with the same interstitial histology on TBBx.We cannot agree with Davis that eosinophilic alveolitis is not part of the spectrum of chronic eosinophilic pneumonias or pulmonary infiltrates with eosinophilia. With a subacute presentation, progression to respiratory failure, steroid-responsive infiltrates, and subsequent relapse, our case is entirely consistent with a chronic eosinophilic pneumonia.2Pearson DJ Rosenow EC Chronic eosinophilic pneumonia (Carrington's). A follow-up study.Mayo Clin Proc. 1978; 53: 73-78PubMed Google Scholar Interesting is the discrepancy between our BAL and TBBx results in demonstrating eosinophilia. Other series have shown eosinophilic BAL fluid and lung tissue eosinophilia in chronic eosinophilic pneumonias.3Dejaegher P Demedts M Bronchoalveolar lavage in eosinophilic pneumonia before and during corticosteroid therapy.Am Rev Respir Dis. 1984; 129: 631-632PubMed Google Scholar A recent review of the applications of BAL suggests that eosinophilic fluid is distinctly unusual in other pulmonary disease.4Crystal RG Reynolds HY Kalicia AR Bronchoalveolar lavage The report of an international conference.Chest. 1986; 90: 122-131Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar However, the correlation between BAL and histologic interstitial cells is variable in other diseases and will likely show such variable correlation in eosinophilic syndromes.The similarity of these three cases to previously identified syndromes does not seem to justify describing a new entity based on BAL.5Whitcomb ME Dixon GF Gallium scanning, bronchoalveolar lavage, and the national debt.Chest. 1984; 85: 719-721Abstract Full Text Full Text PDF Scopus (7) Google Scholar To the Editor: We agree with Davis and co-workers that there are therapeutic implications of eosinophilic bronchoalveolar lavage (BAL).1Davis BW Wilson HE Wall RL Eosinophilic alveolitis in acute respiratory failure.Chest. 1986; 90: 7-9Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar We recently evaluated a 69-year-old white woman with a nonproductive cough of four weeks' duration. She was a nonsmoker and took no medications. She had no history suggesting atopy, asthma or any hypersensitivity pneumonitis. Physical examination was remarkable for tachypnea at rest and bilateral diffuse rales. Cardiac examination results were unremarkable. Her CBC showed no eosinophilia. Arterial blood gas levels (FIo2 21 percent) showed Po2 of 49 and Pco2 of 25. Screening spirometry demonstrated FVC 1.05 (47 percent) and FEV1 .98 (50 percent). Chest roentgenographic film revealed bilateral lower lobe infiltrates (Fig 1). After nondiagnostic sputum evaluation, she was empirically started on intravenous erythromycin therapy. Progressive respiratory failure requiring mechanical ventilatory support rapidly ensued (four days). Bronchoscopy with BAL and transbronchial biopsy (TBBx) was performed. This lung biopsy revealed a lymphocytic interstitial infiltrate without eosinophilia. Special stains were negative for infectious organisms, but BAL fluid demonstrated 30 percent eosinophils. She was treated with intravenous methylprednisolone and was extubated within 48 hrs. At three months, pulmonary function tests showed normal volumes and flows with a normal chest roentgenographic film. Davis1Davis BW Wilson HE Wall RL Eosinophilic alveolitis in acute respiratory failure.Chest. 1986; 90: 7-9Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar did not comment on the course of steroid therapy in his two cases. Our patient was tapered over four months from an initial oral dose of prednisone 50 mg daily. Two months later she relapsed with identical roentgenographic and clinical findings. Bronchoscopy with BAL again showed eosinophilia (25 percent) in lavage fluid with the same interstitial histology on TBBx. We cannot agree with Davis that eosinophilic alveolitis is not part of the spectrum of chronic eosinophilic pneumonias or pulmonary infiltrates with eosinophilia. With a subacute presentation, progression to respiratory failure, steroid-responsive infiltrates, and subsequent relapse, our case is entirely consistent with a chronic eosinophilic pneumonia.2Pearson DJ Rosenow EC Chronic eosinophilic pneumonia (Carrington's). A follow-up study.Mayo Clin Proc. 1978; 53: 73-78PubMed Google Scholar Interesting is the discrepancy between our BAL and TBBx results in demonstrating eosinophilia. Other series have shown eosinophilic BAL fluid and lung tissue eosinophilia in chronic eosinophilic pneumonias.3Dejaegher P Demedts M Bronchoalveolar lavage in eosinophilic pneumonia before and during corticosteroid therapy.Am Rev Respir Dis. 1984; 129: 631-632PubMed Google Scholar A recent review of the applications of BAL suggests that eosinophilic fluid is distinctly unusual in other pulmonary disease.4Crystal RG Reynolds HY Kalicia AR Bronchoalveolar lavage The report of an international conference.Chest. 1986; 90: 122-131Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar However, the correlation between BAL and histologic interstitial cells is variable in other diseases and will likely show such variable correlation in eosinophilic syndromes. The similarity of these three cases to previously identified syndromes does not seem to justify describing a new entity based on BAL.5Whitcomb ME Dixon GF Gallium scanning, bronchoalveolar lavage, and the national debt.Chest. 1984; 85: 719-721Abstract Full Text Full Text PDF Scopus (7) Google Scholar