Levofloxacin-Induced Acute Eosinophilic Pneumonitis: A Case Report and Review

Abstract

SESSION TITLE: Critical Care 1 SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 29, 2017 at 10:45 AM - 12:00 PM INTRODUCTION: Acute eosinophilic pneumonia (AEP) is a rare and potentially fatal entity that requires prompt recognition. While the mechanism of AEP remains unclear, AEP may occur after exposure to toxins, radiation therapy, and drugs. A review of the literature identified only 2 other cases of suspected levofloxacin induced AEP. In this report, we describe a patient with AEP shortly after a course of levofloxacin, who had complete resolution of symptoms and peripheral eosinophilia after steroid therapy. CASE PRESENTATION: Patient was a 49 year old Asian man with seasonal allergies severe enough to require immunotherapy and a recent URI who presented with fever and dyspnea on exertion. He had recently completed a 7 day course of daily levofloxacin 500mg two days prior to presentation. Social history was unremarkable as he denied recent travel, exposure to animals, or changes to his home environment. He presented to the ED with hypoxemia requiring 100% non-rebreather (PaO2 88). Exam was remarkable for bilateral wheezing. Lab studies were significant for a leukocytosis to 15K with an eosinophilia to 19%, and an elevated IgE level of 2229. CT chest revealed bilateral asymmetric ground glass opacities. Empiric antibiotics and steroids were initiated. Direct visualization of the airways via flexible bronchoscopy was notable for thick mucus plugs involving all bronchopulmonary segments. BAL fluid analysis revealed 45% eosinophils. Analysis for typical infectious etiologies including, Tuberculosis, Mycoplasma spp, Legionella spp, Streptococcus, HIV, and Influenza were all negative. Cultures of the blood, sputum, and BAL fluid were unrevealing. Specialized tests including Aspergillus enzyme immunoassay (EIA), IgE, and IgG levels were negative, (1-3)-β-d-glucan assay, Strongyloides EIA were also negative. Dyspnea improved after the third day of methylprednisolone and hypoxemia improved on day five. DISCUSSION: A definitive diagnosis of drug-induced AEP is made with: (1) febrile illness <5 days duration, (2) diffuse bilateral pulmonary infiltrates, (3) hypoxemia (4) bronchoalveolar lavage >25% eosinophils, (5) temporal relationship with exposure, (6) clinical improvement after cessation of drug; and (7) recurrence of symptoms with drug rechallenge. The exact pathophysiology of the drug reaction remains unknown, as there is evidence to suggest both Type I or III hypersensitivities. The incidence of fluoroquinolone hypersensitivity is very low <1 in 50,000. To our knowledge, this is only the third case of eosinophilic pneumonitis secondary to levofloxacin. CONCLUSIONS: While fluoroquinolone antibiotics are well studied, widely prescribed drugs, it is important for physicians to quickly recognize the rare complication of eosinophilic pneumonitis. Reference #1: Steiger D, et al. Ciprofloxacin-induced acute interstitial pneumonitis. Eur Respir J. 2004 Reference #2: Fujimori K, et al. [Levofloxacin-induced eosinophilic pneumonia]. Nihon Kokyuki Gakkai Zasshi. DISCLOSURE: The following authors have nothing to disclose: Christian Castaneda, Christine Feng, Alexander Feldberg, Christopher Lee, Olumayowa Abe No Product/Research Disclosure Information