Eosinophilia with pulmonary infiltrates Peng Chen1, Ye Wang2 & Fuqiang Wen2 1 2
Department of Respiratory Medicine, The Third People Hospital of Chengdu, Chengdu, China Department of Respiratory Medicine, West China Hospital, Sichuan University, Chengdu, China
Keywords Alveolitis, eosinophilia, lymphoma. Correspondence Fuqiang Wen, Division of Pulmonary Diseases, State Key Laboratory Biotherapy of China and Department of Respiratory Medicine, West China Hospital of Sichuan University, Chengdu 610041, China. E-mail:
[email protected]
Abstract Lymphoma is hard to be diagnosed without an exact pathologic evidence. Eosinophilia might be one of its signs. However, some other clinical characteristics such as special contact history, pulmonary infiltrates, and the effectiveness of prednisone treatment could mislead our diagnosis. Here we report a case of lymphoma accompanied with pulmonary infiltrates and clinical feature of eosinophilia.
Received: 19 October 2013; Revised: 17 November 2013; Accepted: 26 November 2013 Respirology Case Reports 2014; 2(1): 36–38 doi: 10.1002/rcr2.41
Introduction Eosinophilia with pulmonary infiltrates is an uncommon clinical characteristic of diffuse lung disease, in particular if the hypothetical cause is lymphoma accompanied with infection of Epstein–Barr (EB) virus. Here we report a case of lymphoma accompanied with pulmonary infiltrates and clinical feature of eosinophilia.
Case Report A 59-year-old man presented with cough for 3 months and fever for 1 month. The patient did not have any contact with wheat bran for the previous 6 months. He reported exposure for 2 days and not repeated. His temperature kept fluctuating around 38°C, usually at night. Physical examination revealed nothing in particular except a slight decrease of breath sound. Routine blood test showed white blood cell was 5.55 × 109/L, neutrophil was 2.66 × 109/L (48%) and eosinophil granulocyte was 1.61 × 109/L (29%). Multiple sputum smears/ cultures, parasitic antibodies, and tumor biomarker tests were negative. Chest computed tomography (CT) revealed patchy shadow and multi-node, which seemed to be distrib36
uted along with the bronchi without hilum of lung and mediastinal lymphadenectasis (Fig. 1A). The patient’s symptoms did not improve after 5 days of treatment with ceftizoxime. Hence, transbronchoscopic and percutaneous lung biopsy were conducted, which identified the nonspecific pathologic changes of chronic inflammatory necrosis and mild eosinophil infiltration. Voriconazole was administered for 8 days. However, the pulmonary infiltration increased (Fig. 1B). Considering the patient’s contact history, we finally stopped the anti-infection treatment and began to use prednisone (40 mg/day). Surprisingly, it was quite helpful to lighten cough and normalize the patient’s temperature. Seven days later, another CT confirmed visually the resorption of lung patchy shadow (Fig. 1C). The patient was asked to continue taking prednisone and extrinsic allergic alveolitis was hypothesized at that stage. One month later, the patient returned with persistent fever. Two masses in the lower lobe and softer tissues infiltrates in bilateral hilar and subcarina were revealed by CT (Fig. 1D). Percutaneous lung biopsy detected tumor cells involved (Fig. 2A) with CD20+ (Fig. 2B) and EBER1/2+ (Fig. 2C), which suggested large B-cell non-Hodgkin’s lymphoma accompanied with infection of EB virus.
© 2014 The Authors. Respirology Case Reports published by John Wiley & Sons Ltd on behalf of The Asian Pacific Society of Respirology. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
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Eosinophilia with pulmonary infiltrates
Figure 1. The computed tomography (CT) imaging at different periods. (A) The patient presented with cough for 3 months and fever for 1 month. Chest CT revealed patchy shadow and multi-node, which seemed to be distributed along with the bronchi without hilum of lung and mediastinal lymphadenectasis. (B) After anti-infection treatment for 2 weeks, the pulmonary infiltration was amplified. (C) After administration with prednisone for 1 week, CT confirmed visually the resorption of lung patchy shadow. (D) One month later, the patient returned with persistent fever. Two masses in the lower lobe and softer tissues infiltrates in bilateral hilar and subcarina were revealed.
Figure 2. The pathologic findings of the patient by hematoxylin-eosin and immunocytochemistry staining. Scale bars: 50 μm. Original magnification: 400×. Percutaneous lung biopsy detected tumor cells involved (A) with CD20+ (B) and EBER1/2+ (C), which suggested large B-cell non-Hodgkin’s lymphoma accompanied with infection of Epstein–Barr virus.
Discussion Special contact history, eosinophilia, pulmonary infiltrates, and the effectiveness of prednisone, all misled our diagnosis. Although we have known eosinophilia may appear in
different diseases such as parasite infection, anaphylactic disease, and tumor [1, 2], this case characterized by eosinophilia and lung patchy shadow without any findings such as lymphadenectasis and pulmonary mass at the early stage has rarely been reported. Especially, the first two
© 2014 The Authors. Respirology Case Reports published by John Wiley & Sons Ltd on behalf of The Asian Pacific Society of Respirology
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Eosinophilia with pulmonary infiltrates
transbronchoscopic and percutaneous lung biopsies both suggested chronic inflammatory necrosis and the effectiveness of treatment with prednisone misled our diagnosis ulteriorly. Hence, was there no way to distinguish such case until the masses emerged in CT? Perhaps the imaging feature could show something. As to acute extrinsic allergic alveolitis, the patchy consolidation or ground-glass opacity usually progressed within 1 week after wheat bran contact and the migratory (repetitive contact) or reversible (after disengagement) trait was suggestive. On the contrary, this patient stayed stable for 3 months after contact and the pulmonary infiltrates unexpectedly developed 6 months later. Pay attention to Fig. 1C, although the infiltrates were obviously absorbed due to administration with prednisone, a mass loomed in the right lower lobe.
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Disclosure Statements No conflict of interest was declared. Appropriate written informed consent was obtained for publication of this case report and accompanying images.
References 1. Brito Babapulle F. 2003. The eosinophilias, including the idiopathic hypereosinophilic syndrome. Br. J. Haematol. 121(2):203–223. 2. Rothenberg ME. 2008. Treatment of patients with the hypereosinophilic syndrome with mepolizumab. N. Engl. J. Med. 358(12):1215–1228.
© 2014 The Authors. Respirology Case Reports published by John Wiley & Sons Ltd on behalf of The Asian Pacific Society of Respirology
