SAVED BY THE BAL: A CASE OF ACUTE EOSINOPHILIC PNEUMONIA AFTER METHYL-NALTREXONE INJECTION

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: Eosinophilic pneumonia (EP) can result as an adverse effect of many drugs. Methyl-naltrexone injection has become increasingly popular this case serves to bring attention to a rare, but potential adverse effects. CASE PRESENTATION: A 44-year-old male with history of alcohol use disorder was brought to the emergency department (ED) by ambulance in acute respiratory failure. He received his monthly naltrexone injection three days prior. The following day, he started having lip swelling, rash, and two days later, had dyspnea. Upon arrival to the ED, he was given two doses of IM epinephrine, as well as methylprednisolone 125 mg IV, and he required BiPAP, after what was thought to be an anaphylactic reaction to naltrexone. Chest x-ray revealed stable bilateral lower lobe opacities, possibly related to aspiration pneumonia, patient was placed on ampicillin-sulbactam. CBC demonstrated increased absolute levels of eosinophils (700k/mm3), anaphylaxis was ruled out with tryptase level of 2.8 (normal <11.5). Patient’s symptoms slightly improved, however patient's eosinophil count continued to trend upwards, as high as 2500k/mm3 four days after presentation. CTA of chest demonstrated no evidence of pulmonary embolism, but did reveal diffuse ground glass opacities consistent with acute infiltrates. Bronchoscopy with bronchoalveolar lavage (BAL) was performed and BAL yielded fluid with eosinophils making up greater than 50% of the WBC's and the fluid was negative for malignant cells. Eosinophilic pneumonia diagnosis was established and steroids were initiated with improvement of symptoms. DISCUSSION: Acute eosinophic pneumonia is characterized by acute onset febrile illness, hypoxemia, diffuse bilateral infiltrates on imaging, and pulmonary eosinophilia with more than 25% eosinophils in BAL. EP is characterized by symptoms lasting less than 1 month and usually less than 1 week. EP will respond rapidly to steroid therapy but early recognition remains important to choose appropriate therapy given mimics such as infection. Several medications have historically been shown to cause EP, in one review of the literature the most commonly cited drugs include antibiotics or anti-inflammatories. Imaging findings typically include bilateral reticular ground-glass opacities that expand as the disease progresses. Methyl-naltrexone is increasingly utilized as an effective treatment for alcohol dependence disorder. Its possible association with EP was initially noted in a large randomized control trial published in JAMA by Garbutt et al. In our review of the literature there have been only four other cases of naltrexone induced eosinophilic pneumonia. CONCLUSIONS: This case demonstrates a likely outcome of eosinophilic pneumonia in a patient receiving methyl-naltrexone injections for alcohol use disorder. It is important to recognize naltrexone as a possible etiology for eosinophilic pneumonia due to its increasing use. Reference #1: Carmi Bartal, MD, MHA, Iftach Sagy, MD, and Leonid Barski, MD. Medicine (Baltimore). 2018 Jan; 97(4): e9688. Published online 2018 Jan 26. Drug-induced eosinophilic pneumonia: A review of 196 case reports Reference #2: Kim H, Ali M, Buch K. Eosinophilic Pneumonia Induced by Injectable Naltrexone. Am J Respir Crit Care Med. 2014;189:A2283 Reference #3: Garbutt JC, Kranzler HR, O'Malley SS, Gastfriend DR, Pettinati HM, Silverman BL, Loewy JW, Ehrich EW; Vivitrex Study Group. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA. 2005 Apr 6;293(13):1617-25 DISCLOSURES: No relevant relationships by Anthony Esposito, source=Web Response No relevant relationships by benison lau, source=Web Response