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An Atypical Case of Eosinophilic Radiation Pneumonitis
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A6497 - An Atypical Case of Eosinophilic Radiation Pneumonitis
Author Block: A. Bommakanti1, R. Masroujeh1, R. El Ghoul2; 1Department of Internal Medicine, University Hospitals – Cleveland Medical Center, Cleveland, OH, United States, 2Division of Pulmonary, Critical Care, and Sleep Medicine, Louis Stokes VA Medical Center, Cleveland, OH, United States.
Introduction: Radiation-induced lung injury is common in lung cancer patients treated with radiation. The majority of patients have mild and self-limited disease but a minority develop a progressive fibrotic disease. Treatment consists of corticosteroids despite limited evidence supporting efficacy. We report an unusual case of rapidly progressive radiation pneumonitis that is eosinophil-mediated yet resistant to corticosteroids.
Case report: A 74 year old man with known COPD was treated for right lung T3N2M0 small cell lung cancer with concurrent chemoradiation. His chemotherapeutic regimen consisted of 4 cycles of Carboplatin and Etoposide, while radiation consisted of 70Gy delivered over 39 fractions 3 months prior to presentation. Patient developed acute hypoxemic respiratory failure 3 weeks following completion of radiation therapy. CT-chest showed reticulonodular and ground glass infiltrates in the irradiated area of right middle and lower lobes. He was empirically started on levofloxacin and prednisone and discharged home. Despite treatment, the patient continued to worsen and presented two weeks later with severe hypoxic respiratory failure requiring mechanical ventilation. Patient underwent bronchoscopy with right middle lobe bronchoalveolar lavage (BAL) showing increased eosinophils (28%). All cultures (bacterial, fungal, and mycobacterial) showed no evidence of growth. Despite broad-spectrum antibiotics (Vancomycin and Aztreonam) and higher dose corticosteroids (Prednisone 80mg), the patient continued to worsen. After four days of mechanical ventilation, family agreed to make patient comfort care and he was terminally extubated.
Discussion: Radiation pneumonitis is usually characterized by two phases: acute and chronic. The acute phase is usually mediated by increased capillary permeability, whereas the chronic phase is mediated by fibroblast proliferation. During the acute phase, typical BAL cell findings show lymphocyte-predominance. Few cases of eosinophil-predominant BAL have been reported in the literature, but all these cases behaved like acute eosinophilic pneumonitis and responded favorably to glucocorticoids with resolution of disease. The rapidly progressive nature of the process, eosinophil-rich BAL, and resistance to steroids make it highly atypical.
Author Block: A. Bommakanti1, R. Masroujeh1, R. El Ghoul2; 1Department of Internal Medicine, University Hospitals – Cleveland Medical Center, Cleveland, OH, United States, 2Division of Pulmonary, Critical Care, and Sleep Medicine, Louis Stokes VA Medical Center, Cleveland, OH, United States.
Introduction: Radiation-induced lung injury is common in lung cancer patients treated with radiation. The majority of patients have mild and self-limited disease but a minority develop a progressive fibrotic disease. Treatment consists of corticosteroids despite limited evidence supporting efficacy. We report an unusual case of rapidly progressive radiation pneumonitis that is eosinophil-mediated yet resistant to corticosteroids.
Case report: A 74 year old man with known COPD was treated for right lung T3N2M0 small cell lung cancer with concurrent chemoradiation. His chemotherapeutic regimen consisted of 4 cycles of Carboplatin and Etoposide, while radiation consisted of 70Gy delivered over 39 fractions 3 months prior to presentation. Patient developed acute hypoxemic respiratory failure 3 weeks following completion of radiation therapy. CT-chest showed reticulonodular and ground glass infiltrates in the irradiated area of right middle and lower lobes. He was empirically started on levofloxacin and prednisone and discharged home. Despite treatment, the patient continued to worsen and presented two weeks later with severe hypoxic respiratory failure requiring mechanical ventilation. Patient underwent bronchoscopy with right middle lobe bronchoalveolar lavage (BAL) showing increased eosinophils (28%). All cultures (bacterial, fungal, and mycobacterial) showed no evidence of growth. Despite broad-spectrum antibiotics (Vancomycin and Aztreonam) and higher dose corticosteroids (Prednisone 80mg), the patient continued to worsen. After four days of mechanical ventilation, family agreed to make patient comfort care and he was terminally extubated.
Discussion: Radiation pneumonitis is usually characterized by two phases: acute and chronic. The acute phase is usually mediated by increased capillary permeability, whereas the chronic phase is mediated by fibroblast proliferation. During the acute phase, typical BAL cell findings show lymphocyte-predominance. Few cases of eosinophil-predominant BAL have been reported in the literature, but all these cases behaved like acute eosinophilic pneumonitis and responded favorably to glucocorticoids with resolution of disease. The rapidly progressive nature of the process, eosinophil-rich BAL, and resistance to steroids make it highly atypical.
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