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A Rare Case of the Pulmonary Infiltration With Eosinophilia: Lung Adenocarcinoma

2017; Elsevier BV; Volume: 152; Issue: 4 Linguagem: Inglês

10.1016/j.chest.2017.08.723

1931-3543

Jiwoon Chang, Jack Dougherty, Julia L. Frydman, Daniel Katzman, Vikramjit Mukherjee,

Pericarditis and Cardiac Tamponade

SESSION TITLE: Student/Resident Lung Cancer SESSION TYPE: Student/Resident Case Report Slide PRESENTED ON: Sunday, October 29, 2017 at 04:30 PM - 05:30 PM INTRODUCTION: The differential diagnosis for reactive eosinophilia is broad, including allergic, infectious, autoimmune, and neoplastic processes. Peripheral eosinophilia has been reported in patients with solid tumors and rarely associated with non-small cell lung carcinoma.1 CASE PRESENTATION: A 66-year-old man presented to the emergency room with one week of progressive dyspnea. History was significant for active 15 pack-year smoking. On arrival, his heart rate was 130 beats per minute with systolic blood pressure of 60 mmHg and oxygen saturation of 80%. Bedside transthoracic echocardiogram was remarkable for a large pericardial effusion. Emergent pericardiocentesis was performed, draining one liter of serosanguinous fluid, with improvement in blood pressure and heart rate. After admission, patient continued to be hypoxemic, requiring a 5-liter nasal cannula. Peripheral blood showed eosinophilia: white blood cells 14,200 cells/µl with 73.6% neutrophils and 7.4% eosinophils. Serum rheumatologic, fungal, and parasitic work-up was sent and negative. Chest CT with intravenous contrast (figure 1a) demonstrated pulmonary emboli within segmental branches of the left lower lobe, bilateral pleural effusions, and diffuse ground glass opacities with interlobular septal thickening. Abdomen and Pelvis CT showed bilateral adrenal masses and abdominal lymphadenopathy concerning for metastatic disease. Given the patient’s ongoing hypoxemia, thoracentesis and bronchoalveolar lavage (BAL) were performed. BAL cell count was significant for 20% eosinophils with fluid cytology positive for adenocarcinoma (figure 1b). Pericardial fluid cytology showed adenocarcinoma of pulmonary origin. DISCUSSION: Paraneoplastic eosinophilia is a diagnosis of exclusion but should be recognized urgently since eosinophilia associated with malignancy suggests a poor prognosis.1 Although the exact pathophysiology of tumor-associated eosinophilia is unknown, in-vivo studies and case reports suggest that interleukin-5 expression from tumor tissue stimulates eosinophil production, activation, and migration.3 In setting of respiratory symptoms, peripheral eosinophilia, and diffuse pulmonary infiltrates of alveoli on chest imaging, PIE should be considered and explored with bronchoscopy with BAL.2 There is no clear role of corticosteroid therapy for treatment of PIE due to malignancy. CONCLUSIONS: PIE requires a thorough diagnostic work-up and may present in setting of lung adenocarcinoma. Paraneoplastic eosinophilia suggests a poor prognosis and tumor dissemination. Reference #1: Verstraeten AS, et al. Excessive eosinophilia as paraneoplastic syndrome in a patient with non-small-cell lung carcinoma: a case report and review of the literature. Acta Clin Belg. 2011;66(4):293-7. Reference #2: Cottin V. Eosinophilic Lung Disease. Clin Chest Med. 2016;37(3):535-56. Reference #3: Pandit R, et al. Non-small-cell lung cancer associated with excessive eosinophilia and secretion of interleukin-5 as a paraneoplastic syndrome. Am J Hematol. 2007;82(3):234-7. DISCLOSURE: The following authors have nothing to disclose: Jiwoon Chang, Jack Dougherty, Julia Frydman, Daniel Katzman, Vikramjit Mukherjee No Product/Research Disclosure Information