Correct
4. Start patient on high dose steroids
Given the current etiology of the EP is unknown and the patient remains unstable with an uptrending WBC despite the current antibiotic regimen. The patient’s antimicrobials should be broadened, and ID consulted for recommendations on infectious workup. The patient can also be started on high dose steroids given they meet the criteria for eosinophilic pneumonia as previously stated. Specific IgE allergen testing, CT scan of chest and a punch biopsy of the skin can be performed but will not change the clinic picture and thus are not immediately indicated.
Hospital course
The patient was started on amphotericin 5mg/kg, doxycycline 100mg PO and ivermectin 200 mcg/kg in addition to fluconazole, levofloxacin and vancomycin after consulting with infectious disease. An extensive infectious and autoimmune workup was completed, and patient was started on IV methylprednisolone. Complete viral respiratory PCR panel and bacterial workups were unremarkable aside from an indeterminate quantiferon. The patient tested negative for aspergillus, cryptococcus, coccidioides, strongyloides, histoplasma, blastomyces, pneumocystis, and toxoplasma gondii. Additional laboratory tests were significant for low C3 but normal C4. Quantitative serum immunoglobulin tests were ordered and detected a low level of IgM, normal levels of IgG/IgA, and elevated levels of IgE. ANA was negative. Given the elevated IgE on serology, he underwent specific IgE allergen testing which showed low levels of serum Ascaris IgE.
CT imaging was performed and showed multiple peripheral and peribronchovascular areas of consolidation (Figure 2). (Note: This patient's presentation was in the pre-COVID-19 era.)
Figure 2. Representative axial images in lung windows from thoracic CT scan.
A punch biopsy of the patient’s skin rash showed edema, vascular dilatation, neutrophils, lymphocytes and eosinophils with some inflammatory cells within the interstitium consistent with urticarial dermatitis. After completing high dose intravenous methylprednisolone, patient was transitioned to prednisone 80 mg daily with a taper. He was extubated four days later with complete resolution of skin symptoms and was downgraded to the general medical floors with no oxygen requirement. Follow up pulmonary function tests (PFTs) three months later were normal.
Which of the following is the most likely cause of this patient’s Eosinophilic Pneumonia (EP)? Click on the correct answer to be directed to the third of four pages.)