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Approach to Eosinophilia Presenting With Pulmonary Symptoms

Published:September 28, 2020DOI:https://doi.org/10.1016/j.chest.2020.09.247
      Eosinophilia with pulmonary involvement is characterized by the presence of peripheral blood eosinophilia, typically ≥500 cells/mm3, by pulmonary symptoms and physical examination findings that are nonspecific, and by radiographic evidence of pulmonary disease and is further supported by histopathologic evidence of tissue eosinophilia in a lung or pleura biopsy specimen and/or increased eosinophils in BAL fluid, usually >10%. Considering that there are a variety of underlying causes of eosinophilia with pulmonary manifestations and overlapping clinical, laboratory, and radiologic features, it is essential to approach the evaluation of eosinophilia with pulmonary findings systematically. In this review, we will describe a case presentation and discuss the differential diagnosis, a directed approach to the diagnostic evaluation and supporting literature, the current treatment strategies for pulmonary eosinophilia syndromes, and the levels of evidence underlying the recommendations, where available. Overall, optimal management of eosinophilic lung disease presentations are directed at the underlying cause when identifiable, and the urgency of treatment may be guided by the presence of severe end-organ involvement or life-threatening complications. When an underlying cause is not easily attributable, management of eosinophilia with pulmonary involvement largely relies on eosinophil-directed interventions, for which biologic therapies are increasingly being used.

      Key Words

      Abbreviations:

      ABPA (allergic bronchopulmonary aspergillosis), AEC (absolute eosinophil count), AEP (acute eosinophilic pneumonia), AERD (aspirin-exacerbated respiratory disease), ANCA (antinuclear antibody and antineutrophil cytoplasmic antibody), CEP (chronic eosinophilic pneumonia), EGPA (eosinophilic granulomatosis with polyangiitis), GPA (granulomatosis with polyangiitis), HES (hypereosinophilic syndrome), MPA (microscopic polyangiitis), PCR (polymerase chain reaction)
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      Linked Article

      • Response
        CHESTVol. 159Issue 4
        • Preview
          We thank Drs John and Kontoyiannis for their interest in our approach to eosinophilia with pulmonary involvement.1,2 As we noted in our review, pulmonary eosinophilia may be associated with diverse causes that have overlapping clinical, laboratory, and radiologic features. The differential diagnosis includes, but is not limited to, eosinophilic granulomatosis with polyangiitis and other vasculitides, hypereosinophilic syndromes, aspirin-exacerbated respiratory disease, eosinophilic pneumonias and bronchitis, allergic bronchopulmonary aspergillosis, a myriad of helminthic and non-helminthic infections, and drug-induced pulmonary eosinophilic syndromes.
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      • Do Not Forget Daptomycin as a Cause of Eosinophilic Pneumonia!
        CHESTVol. 159Issue 4
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          We read with interest the article by Drs Rosenberg and Khoury1 published in CHEST (August 2020) detailing the approach to eosinophilia with pulmonary symptoms, and we congratulate the authors for systematically reviewing the complex topic of causes of the eosinophilic pneumonia (EP) syndrome.1 In this article, the authors elaborate on various conditions, including infections, inflammatory diseases, hematological disorders, and iatrogenic causes, including various drugs that cause eosinophilia with pulmonary symptoms or the EP syndrome.
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