NSAID-INDUCED EOSINOPHILIC PLEURAL EFFUSION: A RARE CASE

Abstract

SESSION TITLE: Disorders of the Pleura 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Non-steroidal anti-inflammatory drugs (NSAIDs) are known to induce systemic eosinophilia, and rare case reports have linked them to eosinophilic pneumonia. The literature, however, does not clearly associate NSAIDs with an eosinophilic pleural effusion. In this case, we present an unusual presentation of an eosinophilic pleural effusion secondary to NSAID use. CASE PRESENTATION: A 49 year-old homeless man with chronic hepatitis C, cholelithiasis, active alcohol and tobacco abuse, and depression, presented to the emergency department with cough and left-sided pleuritic chest pain. Chest x-ray (CXR) showed left lower lobe opacity and he was discharged with a course of azithromycin for presumed community-acquired pneumonia. He then returned for persistent symptoms, and a chest computed tomography (CT) confirmed left lower lobe pneumonia with pleural thickening. He was hospitalized, placed on broader antibiotics, and was given ibuprofen for pleuritic pain. Over the following month, he had several more presentations for persistent symptoms. Serial imaging revealed accumulation of left pleural effusion and laboratory studies were significant for serum eosinophilia ranging from 6.6% to 14.3%. Two separate thoracenteses were performed, yielding blood-tinged exudative effusions with normal pH and an eosinophil-predominance (up to 43% on the cell count differential). Extensive workup for bacterial, mycobacterial, viral, fungal and parasitic causes, as well as pulmonary embolism, and underlying rheumatologic disorders were all negative. He was instructed to discontinue his ibuprofen and was scheduled to follow up in the pulmonary clinic. After a month, repeat serum cell counts with differentials normalized (eosinophil 1.2 %), and the pleural effusion improved. DISCUSSION: Eosinophilic pleural effusions are known to be caused by a variety of medications such as valproic acid, nitrofurantoin, dantrolene, warfarin, and fluoxetine. Upon literature review, it is noted that ibuprofen can cause systemic eosinophilia and also eosinophilic pneumonia. Our patient likely had underlying pleural inflammation from his recent pneumonia. Following the initiation of NSAIDs, the elevated systemic eosinophils likely caused further inflammation to the pleural space, leading to the eosinophil-predominant pleural effusion. CONCLUSIONS: 49 year old male presenting with ibuprofen induced recurrent pleural effusion with eosinophilia resolving with cessation of medication. Further investigation between ibuprofen effects on pleural effusion development should be explored. We recommend caution when prescribing NSAIDs in patients with systemic eosinophilia. Reference #1: Bartal, C., Sagy, I., & Barski, L. (2018). Drug-Induced Eosinophilic Pneumonia. Medicine,97(4), 1-6. Retrieved February 02, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5794373/. Reference #2: Huggins, J. T., & Sahn, S. A. (2004). Drug-Induced Pleural Disease. Clinics in Chest Medicine,25(1), 141-153. Retrieved February 10, 2018, from https://www.sciencedirect.com/science/article/pii/S0272523103001254?via%3Dihub. DISCLOSURES: No relevant relationships by Angela Love, source=Web Response No relevant relationships by Tetsuro Maeda, source=Web Response No relevant relationships by Adam Rothman, source=Web Response No relevant relationships by Reza Samad, source=Web Response No relevant relationships by Gorav Sharma, source=Web Response