RAPIDLY DEVELOPING RESPIRATORY FAILURE IN A NEW SMOKER

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Acute eosinophilic pneumonia (AEP) is a rare cause of respiratory failure and often misdiagnosed initially as community acquired pneumonia (CAP). The clinical and radiologic presentation are similar to CAP or acute respiratory distress syndrome (ARDS), contributing to the difficulty in diagnosis of this entity. An eosinophil count >25% on bronchoalveolar lavage (BAL) is diagnostic. CASE PRESENTATION: A 22-year-old female with no significant past medical history presented to the hospital with fever, night sweats, worsening cough with yellow sputum production and shortness of breath for 3 days. She denied any sore throat, runny nose, hemoptysis, orthopnea or paroxysmal nocturnal dyspnea. No recent travel or sick contacts. She denied any alcohol use, however started smoking 4-5 cigarettes/day over the past week. On admission, she was febrile, tachycardic, tachypneic with a stable blood pressure and an oxygen saturation of 95% on 2L oxygen via nasal cannula. Physical examination revealed a patient in moderate distress and diffuse bilateral coarse crackles on lung auscultation. Blood work showed leukocytosis with bandemia and normal chemistry. Chest X-ray demonstrated diffuse bilateral infiltrate without cardiomegaly or pleural effusion. An echocardiogram showed normal ejection fraction and no valvular abnormalities. She was started on IV ceftriaxone and azithromycin for a diagnosis of CAP. Over the next 2 days, the patient deteriorated, requiring intubation and mechanical ventilation for management of ARDS. A bronchoscopy was performed, and she was found to have 72% eosinophil on BAL. The microbiologic studies were negative. Work up for eosinophilic lung diseases were unremarkable. She was treated with steroid for a diagnosis of AEP and recovered rapidly and completely. DISCUSSION: The occurrence of AEP has been described in a new or former smoker following resumption of smoking. Other risk factors include inhalational exposure and drugs. However, many cases are idiopathic. The diagnosis is often delayed and usually suspected when the patient fails to improve on appropriate antibiotic therapy in presence of risk factors. A diagnosis of AEP is clinched with BAL eosinophil >25% in the absence of other eosinophilic lung diseases. Peripheral eosinophilia is present occasionally but less common in patient with AEP secondary to smoking. The disease improves rapidly with steroid therapy and overall has good prognosis. Relapse is uncommon without resumption of smoking. CONCLUSIONS: Suspicion for AEP in the right clinical setting could expedite the diagnosis and prevent downstream complications from respiratory failure. AEP should be considered in the differential diagnosis of CAP or ARDS in a new or former smoker who resumes smoking. Therapy with steroid results in rapid improvement of symptoms even in patients with ARDS requiring mechanical ventilation. Reference #1: De Giacomi F, Decker PA, Vassallo R, Ryu JH. Acute Eosinophilic Pneumonia: Correlation of Clinical Characteristics With Underlying Cause. Chest. 2017;152(2):379-85. DISCLOSURES: No relevant relationships by Aditi Saha, source=Web Response No relevant relationships by Biplab Kumar Saha, source=Web Response