A 32 y.o. male was smoking meth and complains of shortness of breath.

His CXR is shown below.  What happened?

Our patient had eosinophilic pneumonia from smoking meth. Classically, the pneumonia is peripheral; the opposite of the bat-wing pattern of pulmonary edema, and there is a peripheral eosinophilia. He initially presented with a sat of 72%.  ABG on 15 liters was pH 7.43 PCO2 32 and PO2 59.

Medications, substance abuse and environmental exposure may all cause eosinophilic  pneumonia.   Drugs which frequently cause eosinophilc pneumonia include:  ampicillin, phenytoin (Dilantin), ibuprofen, and daptomycin.  Inhaled substances and cigarette smoke can also cause it.  A firefighter who rescued people during 9/11 in the World Trade Center attack contracted eosinophilic pneumonia.  Eosinophilic granuloma (Langerhans cell histiocytosis) is related to smoke inhalation from cigarettes as well.

Parasites can also cause eosinophilic pneumonia either by living in the lung as part of their life cycle (ascaris, strongyloides and hookworms), migrating to the lungs (paragonimiasis, echinococcus, taenia), or depositing massive numbers of eggs in the lungs through the bloodstream (trichinella, schistosomes, strongyloides, and ascaris) .

 Cutaneous larva migrans (hookworm) of the lung: Loeffler's syndrome.

Cutaneous larva migrans (hookworm) of the lung: Loeffler's syndrome.

 Peripheral rash associated with hookworms.

Peripheral rash associated with hookworms.

Automimmune diseases like eosinophilic granulomatosis with polyangitis or Churg-Strauss also result in eosinophilic pneumonia.  The early stages of this disease is marked by asthma, followed by eosinophilia and then vasculitis of the lungs and GI tract.

 Differential diagnosis of eosinophilic pneumonia

Differential diagnosis of eosinophilic pneumonia

Our patient remained hypoxic and did not tolerate BiPaP, and he was switched to CPAP and remained on this for two days.  His IV solumedrol was changed to prednisone.  He was started on azithromycin, ceftriaxone, and linezolid which was switched to Cipro at discharge. His CXR cleared dramatically and he was discharged on the third hospital day.

 

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Swartz J, Stoller JK. Acute eosinophilic pneumonia complicating Coccidiodes immitis pneumonia: a case report and literature review. Respiration 2009. 77(1):102-6.