Chronic eosinophilic pneumonia is a disease of the lungs infiltrated with eosinophils, usually of 2-6 months or longer duration. Its etiology is unknown and may be related to parasites and drug-induced metabolic reactions, or it may be an autoimmune disease.
Etiology
When the body’s resistance is reduced, it enters the lungs via the respiratory tract causing large lobar or small lobar fusion lesions, with the upper lobes being the most common. The exudate in the lesion is viscous and heavy, causing the middle space to drop down. Bacteria with podoconiosis, when growing and multiplying in the alveoli, cause tissue necrosis, liquefaction, and formation of delayed or multiple abscesses. If the lesion involves the pleura or pericardium, it can cause exudative or purulent effusion lesions with active proliferation of fibrous tissue and easy mechanization, and fibrinous pleurisy can occur early with adhesions. It is most commonly seen in elderly, malnourished, chronic alcoholic, patients with pre-existing chronic broncho-pulmonary disease and systemic failure. The disease is a pulmonary eosinophilic infiltrative disease with a typical duration of 2-6 months or longer. Its etiology is unknown and may be related to parasites and drug-induced metaplasia, or it may be an autoimmune disease. The interstitium, alveoli and bronchioles are infiltrated with leukocytes, mainly mature eosinophils and a few histiocyte nucleated lymphocytes. Eosinophilic granulocytes can be seen in the alveoli in the form of crystallized multinucleated giant cells in sharp ribs, which can form “eosinophilic abscesses”. Some small pulmonary vessels, mainly pulmonary veins, have vasculitis, sometimes with multinucleated giant cells and eosinophilic granulomas.
Pathology
The etiology is generally similar to that of simple pulmonary eosinophilic infiltrates, and it is thought to be a type of Lupus syndrome. Among parasites, hookworms and roundworms are most common. Among the drugs, furantoin is the most common. Other etiologies include coccidioidomycosis and brucellosis. Many patients have allergies, but their true causative agent is unknown.
Clinical features
Patients are mostly young and middle-aged women with fever, cough with mucous sputum, with shortness of breath and hemoptysis. There is also weight loss and night sweats. The peripheral blood eosinophil ratio is mostly in the range of 20%-70%. x-ray chest radiographs show peripheral lamellar shadows without segmental or lobar distribution, often bilateral (“pulmonary edema inversion”). Symptoms and radiographic manifestations may disappear rapidly within 48 hours after glucocorticoid treatment. It can recur in the same localization and become fibrotic or cellular changes after several years. Chest X-rays show peripheral lamellar shadows that are not segmental or lobar in distribution, often bilaterally. The symptoms and chest X-ray may disappear rapidly within 48h after glucocorticoid treatment. They can recur in the same localization and become fibrotic or cellular changes after several years. Glucocorticosteroid treatment is effective and can often return to normal, because it is easy to recur after stopping the drug, so the whole course of treatment needs to be more than one year.
Diagnostic tests
Diagnosis
Simple pulmonary eosinophilic infiltration is also a metaplasia caused by parasites and drugs, with a relatively short course. No treatment is usually required.
Asthmatic pulmonary eosinophilia is characterized by recurrent asthmatic episodes due mainly to Aspergillus, but can also be caused by pollen, drugs and nickel fumes. It is characterized by a large number of eosinophilic infiltrates in the alveoli and interstitium, dilated end bronchi and mucous sputum, and fungal filaments. x-ray chest radiographs show wandering shadows in the upper part of both lungs, and V- or Y-shaped or grape-shaped shadows when bronchial sputum is obstructed. Treatment with glucocorticoids may bring asthma under control and the shadow may dissipate.
Tropical eosinophilia is caused by filariasis and other infections. The lungs are infiltrated with eosinophilic histiocytes and may show a bronchopneumonia distribution with small bronchial necrosis and eosinophilic abscesses. The patient has asthma-like episodes of severe cough with little sputum that cannot be easily coughed out, chest tightness, fatigue, and poor sleep. x-ray chest radiographs show increased texture in both lungs, with corn-like or faint shadows, and interstitial fibrosis in chronic cases. After treatment with anti-filamentous drugs, the symptoms are relieved for several days and the lung lesions disappear more slowly.
Auxiliary examinations: X-ray manifestations: large lobe solid lesions, small lobe infiltrates, abscess formation. The large lobe solid lesions were mostly located in the right upper lobe, and the interlobular fissure was arched down because of the high amount of inflammatory exudate, which was viscous and heavy. Abscesses are seen in inflammatory infiltrates, pleural effusions, and a few present as bronchopneumonia.
Differentiation from bronchiectasis: bronchiectasis is a common chronic bronchial septic disease, mostly secondary to respiratory infections and bronchial obstruction, especially bronchopneumonia in children and young adults after measles and pertussis, due to breaking of the annular bronchial walls and formation of luminal dilatation and deformation. Clinical manifestations: chronic cough with copious pus sputum and recurrent hemoptysis. If there is mixed infection with anaerobic bacteria, there is a foul odor. Hemoptysis may occur repeatedly and to varying degrees, ranging from small amounts of sputum and blood to large amounts of hemoptysis, and the amount of hemoptysis is sometimes inconsistent with the severity of the disease; there are usually no obvious toxic symptoms after bronchial dilatation hemoptysis.
The difference between pneumococcal pneumonia and pneumococcal pneumonia: pneumococcal pneumonia is caused by pneumococcus or streptococcus pneumoniae and accounts for more than half of out-of-hospital infections with pneumonia. The lung segments or lobes are acutely inflamed solid, clinically mild or atypical disease is more common. The onset of the disease is rapid, with high fever, which can rise to 39-40°C within a few hours, and may present with a fever that parallels the pulse rate. Pain in the affected side of the chest may radiate to the shoulders and abdomen, and may increase with coughing or deep breathing. Sputum is scarce and may be bloody or rust-colored. The appetite is sharply reduced, with occasional nausea, vomiting, abdominal pain or diarrhea, sometimes misdiagnosed as acute abdomen.
Simple pulmonary eosinophilic infiltration disease
Eosinophilic infiltrates in the interstitial lung, alveolar wall and terminal bronchial wall are caused by parasites and drugs, and may be asymptomatic, with a light cough of small amounts of mucus sputum and a small or large, wandering chest x-ray. No treatment is usually required.
Asthmatic pulmonary eosinophilia
Pulmonary eosinophilia is an allergic reaction characterized by recurrent asthma attacks caused mainly by Aspergillus. There are numerous eosinophilic infiltrates in the alveoli and interstitium, and the terminal fine bronchi are dilated and filled with thick mucous sputum in which fungal filaments can be found. Chest X-rays mostly show wandering shadows in the upper part of both lungs. Treatment with glucocorticoids and antifungal drugs may result in control of asthma and dissipation of the shadows.
Tropical eosinophilia
Eosinophilic and histiocytic infiltration of the lungs due to infections such as filarial parasites may show a bronchopneumonia distribution with small bronchial necrosis and eosinophilic abscesses. X-rays show increased textures in both lungs, with corn or faint shadows, and in chronic cases, interstitial fibrosis. After treatment with anti-filarial drugs, the symptoms resolved in a few days and the lung lesions disappeared slowly.
Treatment options
Less than 10% of patients may resolve on their own. Adrenocorticotropic hormone is the treatment of choice, and prednisone 30-40mg/d is commonly used. A decrease in body temperature and general improvement can occur after a few hours of medication, and symptoms such as shortness of breath, wheezing and coughing start to improve one or two days later, and X-ray abnormalities often improve after 2 days of medication and return to normal within about 2 weeks, and all clinical manifestations can disappear completely after one month of treatment. Considering that the disease is prone to relapse after discontinuation, maintenance adrenocorticotropic hormone therapy is mostly advocated until 6-12 months, and some patients need to use the drug for several years. Maintenance therapy is usually with prednisone 10mg/d.
Glucocorticosteroid treatment is significant and can often return to normal, because it is easier to relapse when the drug is stopped, so the whole course of treatment needs to be more than 1 year. Early use of effective antibiotics is the key to cure. The principle is the second and third generation cephalosporins combined with aminoglycoside kansen number, such as cefotaxime sodium or ceftazidime IV combined with amikacin or tobramycin intramuscular injection or IV. Piperacillin sodium (oxypiperazine penicillin) in combination with aminoglycosides may also be chosen. In some cases, fluoroquinolones and chloramphenicol are also effective. Aminoglycoside antibiotics, such as gentamicin, kanamycin, tobramycin, and butamycin, can be administered intramuscularly, intravenously, or intratubularly. In severe cases, additional cephalosporins such as cefamandole, cefoxitin, cefotaxime, etc. are appropriate. Piperacillin, meloxicillin in combination with aminoglycosides, and ofloxacin are also effective. In some cases, chloramphenicol, tetracycline and SMZ-TMP are also effective. In severe cases, lung tissue is often damaged, and lobectomy is sometimes required in chronic cases. Patients whose immunity has been reduced by other diseases are prone to bacteremia. The prognosis is worse when other gram-negative bacteria are mixed with the infection.
Precautions
1, Most commonly seen in the elderly, malnutrition, chronic alcoholism, existing chronic bronchopulmonary disease and systemic failure.
2.The onset of the disease is rapid, with high fever, cough, sputum and chest pain.
3, there may be cyanosis, shortness of breath, palpitations, about half of the patients have chills, may appear shock early.
4, should not eat eggplant vegetables, such as tomatoes, potatoes, eggplant, peppers and other alkaloids in tobacco can make arthritis symptoms worse.
Prevention
1, strict implementation of disinfection and isolation system which is mainly for medical personnel and the hospital environment, equipment, strict hand washing before and after contact with patients, gloves, regular environmental and indoor disinfection and ventilation, according to the requirements of regular cleaning and disinfection of respiratory therapy devices, regular replacement of mechanical ventilation and nebulizer lines, etc., to adopt a set of strict nosocomial infection monitoring and prevention program.
2, gastrointestinal decontamination treatment This is a preventive measure commonly used in Europe in recent years, mainly for the susceptible population of nosocomial infection, the purpose is to remove the colonization and growth of bacteria in the stomach and intestines. Methods are whole gastrointestinal decontamination and selective gastrointestinal decontamination method, commonly used for the latter, it is through nasal or oral gastrointestinal non-absorption of polymyxin B, tobramycin (gentamicin or neomycin, etc.) and dicloxacillin B, for 5 days, and daily systemic application of cephalosporins, from the oropharynx and gastrointestinal tract to remove aerobic bacteria without reducing the number of anaerobic bacteria, its preventive effect is particularly obvious in gram-negative bacilli, according to The authors statistics about the literature, decontamination group almost no secondary pneumonia and respiratory tract infection of Klebsiella pneumoniae (individual infection of drug-resistant strains).
3, protection of the acidic barrier of the stomach is mainly in the prevention of stress ulcers, the application of thioglycollate drugs, it can prevent stress ulcer bleeding, but also because it has adsorption of gastric mucosa, change the gastric mucus, increase the content of prostaglandins in the gastric lumen, absorption of pepsin, and does not change the acidic environment in the stomach, thus effectively play a role in preventing ulcers and preventing infection. Moreover, according to the literature, aluminum thioglycollate still has intrinsic bactericidal activity, and a series of studies have shown that the incidence of pneumonia in the application of antacids group is 23%-35%, while the incidence of pneumonia in the application of aluminum thioglycollate group is 10%-19%.
Held et al. used IgM monoclonal antibodies induced from Klebsiella pneumoniae podocyte polysaccharide injected into experimental animals to prevent pneumonia, compared with the control group, regardless of the rate of organ involvement, the number of bacteria in the infected tissue, histological changes in the lung, the prevention group was much better than the control group, but this MAb has not yet prevented Klebsiella pneumoniae However, this MAb did not yet prevent the entry of K. pneumoniae into the lungs, but rather accelerated the absorption of the infection and enhanced the lung’s ability to eliminate bacteria. Some similar experiments have been reported, but mature vaccines and antibodies are not yet available for clinical use and further studies are needed. Klebsiella pneumoniae pneumonia has been endangering human beings for more than a century. With the development of science, the continuous improvement of examination and treatment methods, and the progressive understanding of human beings, we believe that we can further reduce its incidence and death rate and make more progress.