From the (excellent) August Parkland MICU team and Tri we have a CXR for today’s image challenge.
We had one correct answer which I think came from Arjun… Nitin’s answer of ‘get this man some steroids!’ will also be accepted.
Hit “read more” for the case and answer.
Answer: this CXR is classic representation of the “reverse batwing” appearance (also known as “photonegative pulmonary edema”), eosinophilic pneumonia should cross your mind!
This CXR finding is characterized by peripheral opacities with sparing of the perihilar region. This carries a fairly narrow differential which includes chronic eosinophilic pneumonia, BOOP, vasculitis, sequelae of PE, or contusion (in the setting of trauma).
56yo Vietnamese male with a history of ALL s/p stem cell tx (2012) c/b GVHD (skin only, treated with sirolimus in 2013) and chronic ITP presents with SOB and pulse ox reading 70% on RA in the ED with improvement to mid 90s on non-rebreather. Labs notable for a peripheral eosinophilia.
Based on imaging and labs the team was initially concerned for chronic eosinophilic pneumonia. CEP is diagnosed with presenting typical symptoms and imaging, and BAL showing >25% eos (typically >40%). CT chest would be expected to show peripherally predominant airspace consolidations, classically in a middle or upper lobe predominance with GGOs, nodules, and reticulation less common and usually in later stage of disease.
The patient’s clinical condition precluded bronchcoscopy. He slowly responded over the next week and was discharged on HD 10 with improved imaging and a long course of steroids.
How do you differentiate between chronic and acute eosinophilic pneumonias? Here is a nice chart highlighting their characteristics
A quick point about treatent: steroids! Eosinophilic pneumonias are known for their impressive response to steroid administration, often feeling better with markedly improved imaging in a matter of days. If your patient is not responding to steroids question your diagnosis of eosinophilic pneumonia.
Switching courses slightly, if you have a patient with pulmonary eosinophilia (defined as >25% eosinophilias on BAL) here is a great chart to help you with your differential.
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