Case of the Month 7
January 2016
History:
67 year old male, non smoker, presents with over a month history of fevers, chills,
anorexia and malaise despite antibiotic treatment for presumptive diagnosis of
community acquired pneumonia by GP
Case of the Month 7
Case of the Month 7
Case of the Month 7
Case of the Month 7
Case of the Month 7
What is your
diagnosis?
Case of the Month 7
Question:
What are the key
findings on this
chest radiograph?
Case of the Month 7
Answer:
• Bilateral air-space
consolidation
• Subpleural,
peripheral and upper
lobe distribution
Case of the Month 7
Question:
What are the key
findings on the CT
images on lung
windows?
Case of the Month 7
Answer:
• Bilateral air-space
consolidation with
air-bronchograms
• Peripheral and
subpleural
• Upper lobe
predominant
Case of the Month 7
Question:
What are the key
findings on the CT
images on
mediastinal
windows?
Case of the Month
Question:
• Bilateral hilar and
mediastinal
adenopathies
Case of the Month 7
Additional clinical
information:
• Previously healthy
except for adult onset
asthma
• Meds: Ventolin
• Allergies: Ragweed
• WBC: 14.1 with
eosinophilia 3.2
• BAL: 72% eosinophils
Case of the Month 7
Before treatment
After treatment
Case of the Month 7
What is your
diagnosis?
Case of the Month 7
Answer:
Chronic Eosinophilic
Pneumonia
Case of the Month 7
Chronic Eosinophilic Pneumonia
Discussion
 Idiopathic condition characterized by
chronic infiltration of the lung by
eosinophils
 Epidemiology
• History of asthma or atopy in 50%
• 90% of patients are nonsmokers
(smoking may be protective)
• Peak incidence in 5th decade
• F>M, 2:1
Case of the Month 7
Chronic Eosinophilic Pneumonia
Discussion
 Symptoms:
• Insidious onset of fever, malaise,
weight loss, and dry cough
 Labs:
• Peripheral blood eosinophilia
• Eosinophilia in bronchoalveolar
lavage
 ~>40% (normal is <1%)
Case of the Month 7
Chronic Eosinophilic Pneumonia
Discussion
 CXR:
• Peripheral consolidation involving
mainly the upper lobes
 “Photographic negative of
pulmonary edema”
 CT:
• Peripheral consolidation and/or
GGO
• Upper lobe predominance
• Bilateral but can be asymmetric
• Septal thickening
Case of the Month 7
Chronic Eosinophilic Pneumonia
Discussion
 CT – LESS COMMON FINDINGS:
•
•
•
•
Centrilobular nodules
Air-space nodules
“Crazy paving pattern”
Streaky or band-like opacities –
(more often during improvement)
• Reactive mediastinal/hilar
lymphadenopathy has been
described
• Pleural effusions <10%
Case of the Month 7
Differential Diagnosis
Chronic Eosinophilic Pneumonia
 Simple pulmonary eosinophilia
(Loeffler syndrome)
• Minimal or no pulmonary symptoms
• Migratory opacities
• Resolves spontaneously
 Churg-Strauss
•
•
Lobular distribution of consolidation
Frequently associated with centrilobular
nodules and ground glass opacity
 Organizing Pneumonia
•
•
•
•
Nodules and masses, reticular opacities,
non-septal lines, bronchodilation more
common
Peribronchial distribution more common
Lower vs upper lung zone
Not as strongly associated with
eosinophilia, BAL usually shows more
lymphocytes
Authors: Danielle Walker and Anastasia Oikonomou
Case of the Month 7
Chronic Eosinophilic Pneumonia
Discussion
 Treatment:
 Dramatic response to
corticosteroids
 Prognosis:
 Recurrence/relapse in >80% of
patients after steroid withdrawal
Further Reading
• JeongYJ, Kim KI, Seo IJ et al. Eosinophilic lung diseases: a
Chronic Eosinophilic Pneumonia
clinical, radiologic, and pathologic overview.
Radiographics 2007;27:617-37
• Mayo JR, Muller NL, Road J et al. Chronic eosinophilic
pneumonia: CT findings in six cases. AJR 1989;153:727–30
• Johkoh T, Muller NL, Akira M, et al. Eosinophilic lung
diseases: diagnostic accuracy of thin-section CT in 111
patients. Radiology 2000;216:773–80
• Kim Y, Lee KS, Choi DC et al. The spectrum of eosinophilic
lung disease: radiologic findings. J Comput Assist Tomogr
1997;21:920-30
• Arakawa H, Kurihara Y, Niimi H et al. Bronchiolitis
obliterans with organizing pneumonia versus chronic
eosinophilic pneumonia. AJR 2001;176:1053-8
• Marchand E, Reynaud-Gaubert M, Lauque D et al.
Idiopathic chronic eosinophilic pneumonia. A clinical and
follow-up study of 62 cases. Medicine 1998; 77: 299-312
Authors: Danielle Walker and Anastasia Oikonomou
Toronto, Canada