Thursday, October 13, 2005

IgE

What causes a high IgE (4000) with only 1% eosinophils on the CBC with diff?
A CT is shown here

6 comments - CLICK HERE to read & add your own!:

Arenberg said...

The highest IgE level I ever saw was in a man with birds...lost and lots of birds. He had an IgE level of >25,000 and HP on a lung biopsy, but his eosinophil level was higher than your patient. This CT sure looks like HP to me, but I have alsoe see levels on the 1000s in people with ABPM, although they had more obvious bronchiectasis. Ther are rare instances of "Hyper-IgE" syndrome, but I am still gonna go with HP.

Jennings said...

Here is the reading on the wedge biopsy:
The right upper lobe lung biopsy has both interstitial pneumonitis with a
BOOP-like injury pattern as well as patchy bronchopneumonia. It is unclear if these two findings represent concomitant injury or an acute injury(bronchopneumonia) superimposed upon an underlying sub-acute injury pattern(BOOP).The latter possibility may better fit the clinical and radiographic findings.

Arenberg said...

I'd buy that the CT findings are consistent with idiopathic BOOP, but as has been beaten to death here and eslewhere, BOOP is a non-specific pattern of response to some injury. A BAL, if positive for an eosinophilic cell population would still suggest chronic eosinophilic pneumonia. No eosinophils on the biopsy? The biopsy you describe could still be HP if you ask me. How confident are you in the pathologist? Sometimes a pathologist will change their interpretation if given more history. Have you talked with the pathologist to give them the story?

Jennings said...

I told pathologist I was suspecting HP, but he saw no definitive evidence on the biopsy. The biopsy, although via VATS, was pretty small. He saw BOOP-like pattern, but agrees that this does not rule out HP, since, as you pointed out, BOOP is just the nonspecific lung injury.
There were no eosinophils on biopsy. However, I am not sure if the patient had already been started on prednisone when that biopsy was performed.

Arenberg said...

Any follow up on this Jeff?

Jennings said...

Not much. A follow up IgE was 2600. She had a moldy basement so I was thinking this may be related. An HP panel was sent. What's the best way to check for mold? skin test or serum for IgG's?