Correct!
2.
Bronchoscopy with bronchoalveolar lavage
The presence of peripheral eosinophilia may be noted in a number of conditions, but, in the context of peripheral lung opacities detected at thoracic imaging, the differential diagnostic considerations narrow to primarily include chronic eosinophilic pneumonia, Churg-Strauss syndrome, pulmonary toxic mediation reactions, and rare disorders associated with eosinophilia, such as parasitic infection, and simple pulmonary eosinophilia (Löffler syndrome). Serological assessment for vasculitis, stool analysis for ova and parasites, and review of medication usage are all appropriate next steps for this patient’s management. However, the imaging and laboratory features do not suggest non-tuberculous mycobacterial infection, nor are they highly suggestive of gastroesophageal reflux disease, and therefore assessment for these conditions is not immediately required. Fungal infection remains a possibility, but less likely than other causes of peripheral eosinophilia noted previously, and therefore presumptive anti-fungal therapy is not indicated. While a vasculitis, particularly Churg-Strauss syndrome, remains possible, thoracic MR assessment for this disorder is premature. The next appropriate step for the management for this patient is bronchoscopy with bronchoalveolar lavage.
The patient subsequently underwent bronchoscopy with bronchoalveolar lavage, which disclosed 40% eosinophilia in the lavage fluid. Serological assessment for vasculitis and stool analysis for ova and parasites were both unremarkable. The constellation of clinical, laboratory, and imaging features was considered consistent with chronic eosinophilic pneumonia, and corticosteroid therapy was subsequently initiated and the patient rapidly improved over the next few days.
Diagnosis: Chronic eosinophilic pneumonia
References