A 43-year-old construction worker comes to the physician with intermittent fever, cough, and shortness of breath over the last 4 months. He also complains of night sweats and reports a 4.5-kg (10-lb) weight loss. He has no hemoptysis. The patient has no medical problems and does not use tobacco, alcohol, or illicit drugs.
Bilateral scattered wheezes are heard on physical examination. There are no cardiac murmurs. The spleen is not palpable, and there are no skin rashes or lymphadenopathy.
Rapid HIV test is negative. Chest x-ray reveals bilateral pleural-based dense infiltrates involving upper and lower lobes. The infiltrates spare the central and perihilar lung regions.
Which of the following is the most likely diagnosis?

Question

A 43-year-old construction worker comes to the physician with intermittent fever, cough, and shortness of breath over the last 4 months.  He also complains of night sweats and reports a 4.5-kg (10-lb) weight loss.  He has no hemoptysis.  The patient has no medical problems and does not use tobacco, alcohol, or illicit drugs.
Bilateral scattered wheezes are heard on physical examination.  There are no cardiac murmurs.  The spleen is not palpable, and there are no skin rashes or lymphadenopathy.
Rapid HIV test is negative.  Chest x-ray reveals bilateral pleural-based dense infiltrates involving upper and lower lobes.  The infiltrates spare the central and perihilar lung regions.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_98df_20fd_853d_cb5c648d0dae_MD0002_00 This patient's presentation suggests eosinophilic pneumonia, which can be further divided into acute (AEP) and chronic (CEP) eosinophilic pneumonia. AEP typically follows a rapid course and is more common in smokers. CEP patients are usually nonsmokers, and over 50% have a history of asthma (preceding or after symptom onset). CEP presents with insidious onset of fever, cough, progressive dyspnea, wheezing, weight loss (often marked), and night sweats. Unlike in AEP patients, hypoxemic respiratory failure is rare. Chest radiograph shows bilateral peripheral or pleural-based opacities ("photographic negative" of pulmonary edema) sparing the perihilar and central lung regions, which is virtually pathognomonic for CEP. Laboratory studies show peripheral eosinophilia > 6%, elevated erythrocyte sedimentation rate and C-reactive protein levels, and thrombocytosis. Bronchoalveolar lavage with > 25% eosinophils is highly suggestive of CEP. Lung biopsy usually shows interstitial and alveolar eosinophils with multinucleated giant cells and associated bronchiolitis obliterans with organizing pneumonia. AEP and CEP usually respond within 48 hours to glucocorticoids (intravenous for AEP, oral for CEP) with symptom improvement, resolution of x-ray findings, and decreased eosinophilia. Lack of improvement suggests an alternate diagnosis. Relapses occur in up to 50% of CEP but are infrequent in AEP. Treatment is continued for 3 months with gradual tapering over the next 3 months. (Choice A) Asbestosis is more common in plumbers, carpenters, electricians, and janitors. Patients usually present 20-30 years after initial exposure with chronic dyspnea (cough and wheezing are unusual). Spirometry shows a strictly restrictive pattern with no airflow obstruction. Chest imaging usually reveals bilateral multinodular or reticular opacities and pleural plaques. (Choice C) Idiopathic pulmonary fibrosis typically presents between ages 50-70 with progressive dyspnea on exertion and chronic dry cough. Physical examination shows clubbing (50% of patients) and late inspiratory crackles. Chest radiographs reveal diffuse interstitial opacities with reduced lung volumes. (Choice D) Pulmonary alveolar proteinosis (PAP) is a diffuse lung disease due to accumulation of periodic acid-Schiff-positive lipoproteinaceous material in distal air spaces of the lung. PAP may present similarly to CEP (eg, fever, progressive dyspnea, cough, weight loss), but chest imaging usually shows bilateral symmetrical alveolar opacities that are centrally located ("bat-wing" distribution). Eosinophilia is not a feature of PAP. Educational objective: Chronic eosinophilic pneumonia is characterized by respiratory symptoms, eosinophilia (peripherally and > 25% on bronchoalveolar lavage), and peripheral pulmonary infiltrates on chest imaging. Unlike acute eosinophilic pneumonia, onset of symptoms is gradual and respiratory failure is rare. Both types of eosinophilic pneumonias respond dramatically to glucocorticoids. __________ References: Chronic eosinophilic pneumonia: a case report and review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/19830005) Acute eosinophilic pneumonia following cigarette smoking: a case report including cigarette-smoking challenge test. (http://www.ncbi.nlm.nih.gov/pubmed/12487181) Pulmonary eosinophilia. (http://www.ncbi.nlm.nih.gov/pubmed/18197481) Chronic eosinophilic pneumonia: CT findings in six cases. (http://www.ncbi.nlm.nih.gov/pubmed/2773727)

A 43-Year-Old Construction Worker Comes to the Physician with Intermittent