Monday, July 24, 2006

More on the woman with eosinophilia

Well, as you might remember, this patient with a past medical history of asthma had had a few months of dyspnea and malaise. A peripheral showed 42% eosinophils and a BAL showed 20% eosinophils. A transbronchial biopsy showed eosinophilic infiltration. Micro was negative. Stool O&P was also negative.
She was given steroids with subjective improvement. However, I am not entirely satisfied with a diagnosis of chronic eosinophilic pneumonia. Here are her radiographs:



Now her amylase and lipase are elevated which does not go with eosinophilic pneumonia, and I don't have a good reason for that. Any thoughts out there? If it is parasitic, at least she is not worsening on the steroids....

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

Baleeiro said...

Jeff, did u get the results on the ANCA?
Parasites should not be hard to find if they were causing of all her symptoms (between stool O&Ps and BAL cytology) and their absence makes it less likely. Nonetheless if you are still curious there are commercially avialble ELISAs for things like Strongyloides and you could rule that out and feel more comfortable.

Jennings said...

The p and c-anca were negative. I re-sent the O&P because I was not sure about the sensitivity of this test. You're right that you would expect this to be very positive, if the patient had eosinophils in the lung already.
Doesn't Ascaris also cause pancreatitis? Also, this would be the one parasite that would go with someone that doesn't have a significant travel history....

Baleeiro said...

Ascaris can cause pancreatitis when the worm migrate the wrong way. Stool sampling for ascaris usually has good sensitivity because they produce so many eggs... There is available serology for that as well.

Anonymous said...

Could this be ANCA negative CSS?

Jennings said...

True, CSS can be ANCA negative. TBBX showed no vasculitis but this could be due to sampling error or because the CSS is not yet in the vasculitic stage. Either way, treatment is with steroids; if there is less than optimal response or if there is renal or skin involvment, at that point I would consider a more definitive (i.e. open lung) biopsy.

Muhammed said...

I have a problem with another patient: IgE level of 10000 on steroids!! uric acid kidney stones, and sever sinus polyps!
Biopsy of these polyps are non diagnostic, all skin and blood immuno tests are neg, all smears and cultures for fungi, AFB, Bacteria are negative! now he has acute renal failre because of obstruted uropathy! any I dea?