Tuesday, July 11, 2006

Are the Eos related to the ILD?

This is a 69 y/o man sent to us for a persistent cough. He quit smoking some 34 years ago and has been fairly healthy. Dry cough is his major complaint and he does not complain of dyspnea.
No other pertinent family or social Hx.
His exam was remarkable for bibasilar "dry" crackles. No clubbing.
PFTs revealed FVC and FEV1~ 53% with a TLC~ 60% and DLCO also ~65%.
CT scan is as seen below. He had had some lab work prior to seeing us and we ordered some other tests. Of not he had a peripheral eosinophilia (11.2% - 850) and high IgE (670), ESR was 58 and ANA was negative.
A bronch revealed no eosinophils, fairly pauci-cellular BAL, negative Cxs and smears and TBBX showed some interstitial fibrosis, pneumocyte hypertrophy but was basically non-specific.
Would you regard this as "just" IPF or would you make anything out of the Eos and IgE?

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

Arenberg said...

I am wrong as often as not when it comes to how our radiologists would read this, but in isolation, the CT looks more consistent with NSIP than UIP, and therefore I'd pursue the surgical biopsy.

If you had told me about the peripheral eos, and not the bronch, I'd say bronch first, but you've done that, and in this case, the peripheral eos may be a red herring as far as helping you explain the ILD.

Jeff H said...

Yea, I'm not sure what to make of the peripheral Eos/IgE in this patient. I agree with DA; I would not consider this a "classic" CT scan for UIP. There seems to be quite a bit of ground glass, and although there may be some "honeycombing" toward the bases, I don't think that it's classic.

So, in either case, I think the next step is a surgical lung biosy.

Jennings said...

I agree the peripheral eos may not be related, since the BAL was negative for eosinophils. In addition, the CT looks like some ground glass, but how many mm were the slices? I agree NSIP or fibrotic NSIP are possibilities. An open lung would allow you to look for this pattern or to see if there is eosinophilic infiltration, etc.

Anonymous said...

This seems like a case of PIE syndrome. A complete drug history should be elicited if not done yet. Helminthic infections should be ruled out, depending on the patient's geographic location and travel history. DIP, CVD associated ILD and Hodgkin are also known to be associated with peripheral eosinophils.

Mendez said...

Agree with anonymous and comments above. Although unlikely, I would consider ABPA given the pretty high IgE (though not over 1000), peripheral Eos, and central bronchiectasis. Lack of productive cough and restrictive defect obviously point away from this Dx. How long has he had the cough? Any history of asthma? Travel hx, hobbies?
I would consider RAST for Aspergillus and/or Aspergillus skin test.