October 2013, Vol 144, No. 4_MeetingAbstracts Chest Infections | October 2013
Chronic Cough and Eosinophilia Nadia Morgan, MBBS; Steven Weiss, MD; James Mahoney, MD SUNY Downstate Medical Center, Brooklyn, NY Chest. 2013;144(4_MeetingAbstracts):247A. doi:10.1378/chest.1690553
Abstract SESSION TITLE: Pneumonia and Pneumonitis SESSION TYPE: Medical Student/Resident Case Report PRESENTED ON: Sunday, October 27, 2013 at 04:15 PM - 05:15 PM INTRODUCTION: Tropical pulmonary eosinophilia (TPE) is a rare but severe manifestation of infection with the lymphatic filarial parasites Wuchereria bancrofti and Brugia malayi . These parasites are endemic only in tropical and subtropical regions, however increased international travel has extended the presentation of this condition to regions outside of its geographical boundaries . CASE PRESENTATION: A 70-year-old hypertensive Afro-Caribbean woman presented to the hospital for evaluation of shortness of breath. The patient had recently immigrated to the United States from Guyana. She complained of a 1-year history of paroxysmal nocturnal non-productive cough with dyspnea and wheezing. She denied fever or chills but reported a 40-pound involuntary weight loss during this 1-year period. She had been hospitalized previously in Guyana for evaluation of these symptoms, but no definitive diagnosis was reached. On presentation to our hospital she was afebrile, hemodynamically stable, and not hypoxic. Physical examination was significant for marked cachexia and bilateral expiratory wheezing. Laboratory investigations revealed an absolute eosinophil count of 4.0 x 109 eosinophils/L and an elevated serum IgE concentration but were otherwise unremarkable. Chest x-ray and CT angiogram of the chest were normal. Pulmonary function tests revealed minimal obstructive lung disease with insignificant response to bronchodilators and a moderate decrease in diffusing capacity. Numerous diagnoses were considered, including Churg-Strauss syndrome, allergic bronchopulmonary aspergillosis and TPE. Serological tests for filarial-specific IgG4 antibodies were sent to the Center for Disease Control and were markedly elevated. A presumptive diagnosis of TPE was made. She received a 21-day-course of therapy with Diethylcarbamazine (DEC), and experienced rapid improvement in symptoms. At 12-month follow up she remained asymptomatic with a normal eosinophil count (0.4 x 109 eosinophils/L).
DISCUSSION: The clinical manifestations of infection with filarial parasites may range from an asymptomatic state to the more critical and potentially fatal TPE . A high clinical index of suspicion for TPE is required as its symptoms are non-specific and it may mimic other diseases. Delay in its diagnosis and treatment may lead to long-term sequelae of chronic interstitial fibrosis and progressive respiratory failure . CONCLUSIONS: TPE is an often elusive but important diagnosis to make in patients presenting from filarial endemic countries. Early initiation of therapy with DEC portends a good prognosis with reduced morbidity and mortality. Reference #1: Vijayan VK. Tropical pulmonary eosinophilia: pathogenesis, diagnosis and management. Curr Opin Pulm Med. 2007; 13(5):428-33. Reference #2: Boggild AK, Keystone JS, Kain KC. Tropical pulmonary eosinophilia: a case series in a setting of nonendemicity. Clin Infect Dis. 2004; 39(8):1123-8. Reference #3: Ong RK, Doyle RL. Tropical pulmonary eosinophilia. Chest. 1998; 113(6):16739. DISCLOSURE: The following authors have nothing to disclose: Nadia Morgan, Steven Weiss, James Mahoney No Product/Research Disclosure Information