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Asthma, Eosinophilia, and Transient Pulmonary Infiltrates in a Young Man
I
ROENTGENOGRAM OF THE MONTH
Asthma, Eosinophilia, and Transient Pulmonary Infiltrates in a Young Man Om P. Shutma, M.D., F.C.C.P. and Leon S . Gottlieb, M.D., F.C.C.P.*
his 20-year-old Negro man who has had bronTchial asthma since infancy, was admitted for 'From the Pulmonary Service, Department of Medicine University of Southern California School of Medicine, and Los Angeles County-University of Southern California Medical Center, Los Angeles. Reprint requests: Dr. S h a m , USC School of Medicine, 2025 Zonal Avenue, Los Angeks 90033
evaluation of increased frequency of asthmatic episodes and transient pulmonary infiltrates. Laboratory findings were as follows: Hgb, 14.0 gm percent, WBC 14,600 mms; P 64 percent; L 25 percent; M 7 percent; and E 14 percent. The peripheral eosinophil count varied from 3 to 19 percent. Tuberculin, histoplasmin, and coccidioidin skin tests were negative. Figures 1and 2 were taken two months apart.
CHEST, VOL. 65, NO. 1, JANUARY, 1974
ROENTGENOGRAM OF THE MONTH
Diagnosis: Aspergillus Hypersensitioity
The serial chest roentgenograms (Fig 1, 2) demonstrated fluctuating parenchymal infiltrates. Sputum smears showed numerous eosinophils; 12 cultures yielded Aspergillus species. Precipitating antibodies against Aspergillus were found in the serum. A bronchogram (Fig 3) revealed proximal bronchiectasis involving the medium-sized and sparing the peripheral bronchi. The presence of pulmonary infiltrates and systemic eosinophilia with or without sputum eosinophilia or asthma is seen in a variety of conditions, including the syndrome of pulmonary infiltrate with eosinophilia or PIE, Loeffler's syndrome, eosinophilic pneumonia, tropical eosinophilia, tuberculosis, brucellosis, coccidioidomycosis, sarcoidosis, berylliosis, parasitic infestation, Hodgkin's disease, eosinophilic granuloma, collagen disorders, and drug hypersensitivity. However, in an asthmatic or atopic individual, pulmonary eosinophilia often indicates a
reaction to Aspergillus, a clinical syndrome known as allergic bronchopulmonary aspergillosis. Excessive production of mucus results in mucoid impaction in the larger bronchi, often appearing roentgenographically as branching spindle-shaped shadows. These plugs are expectorated, leaving dilated bronchi of the type seen in Figure 3 (arrow). The condition seems to be more common in England than in the US.'-' Pepys4 has suggested that atopic subjects become sensitized to Aspergillus and a dual type of hypersensitive response develops: type I (immediate) which is mediated by IgE (reaginic) antibodies, responsible for wheal and flare skin reaction, eosinophilia, and asthma; and type I11 (Arthus) which is mediated by IgG (precipitating) antibodies, responsible for delayed Arthus skin reaction, pulmonary infiltrates, bronchiectasis, and serum precipitins. The therapy for these patients include nystatin inhalation, primaricin aerosols, and corticosteroids. Some of these patients may recover spontaneously; in others extensive bronchiectasis and cor pulmonale super~ene.~ ACKNOWLEDGMENT: We are teful to Dr. J. Pep Brompton Hospital, London, ~ n g c d ,for estimating serum precipitin antibodies against Aspergillus.
1 Hinson KFW, Moon AJ, Plummer AS: Bronchopulmonary aspergillosis: a review and a report of 8 new cases. Thorax 73:317, 1952 2 Campbell MD, Clayton YM: Bronchopulmonary aspergillosis: a correlation of the clinical and laboratory findings in 272 patients investigated for bronchopulmonary aspergillosis. Am Rev Resp Dis 89:186. 1964 3 Edge JR, Stansfield D, Fletcher DE: Pulmonary aspergillosis in an unselected hospital population. Chest 59:407, 1971 4 Pepys J: Hypersensitivity diseases of the lungs due to fungi and organic dusts. Monographs in Allergy (vol 4, 1st ed) Basel, S Karger, 1969
CHEST, VOL. 65, NO. 1, JANUARY, 1974
ROENTGENOGRAM OF THE MONTH
Asthma, Eosinophilia, and Transient Pulmonary Infiltrates in a Young Man Om P. Shutma, M.D., F.C.C.P. and Leon S . Gottlieb, M.D., F.C.C.P.*
his 20-year-old Negro man who has had bronTchial asthma since infancy, was admitted for 'From the Pulmonary Service, Department of Medicine University of Southern California School of Medicine, and Los Angeles County-University of Southern California Medical Center, Los Angeles. Reprint requests: Dr. S h a m , USC School of Medicine, 2025 Zonal Avenue, Los Angeks 90033
evaluation of increased frequency of asthmatic episodes and transient pulmonary infiltrates. Laboratory findings were as follows: Hgb, 14.0 gm percent, WBC 14,600 mms; P 64 percent; L 25 percent; M 7 percent; and E 14 percent. The peripheral eosinophil count varied from 3 to 19 percent. Tuberculin, histoplasmin, and coccidioidin skin tests were negative. Figures 1and 2 were taken two months apart.
CHEST, VOL. 65, NO. 1, JANUARY, 1974
ROENTGENOGRAM OF THE MONTH
Diagnosis: Aspergillus Hypersensitioity
The serial chest roentgenograms (Fig 1, 2) demonstrated fluctuating parenchymal infiltrates. Sputum smears showed numerous eosinophils; 12 cultures yielded Aspergillus species. Precipitating antibodies against Aspergillus were found in the serum. A bronchogram (Fig 3) revealed proximal bronchiectasis involving the medium-sized and sparing the peripheral bronchi. The presence of pulmonary infiltrates and systemic eosinophilia with or without sputum eosinophilia or asthma is seen in a variety of conditions, including the syndrome of pulmonary infiltrate with eosinophilia or PIE, Loeffler's syndrome, eosinophilic pneumonia, tropical eosinophilia, tuberculosis, brucellosis, coccidioidomycosis, sarcoidosis, berylliosis, parasitic infestation, Hodgkin's disease, eosinophilic granuloma, collagen disorders, and drug hypersensitivity. However, in an asthmatic or atopic individual, pulmonary eosinophilia often indicates a
reaction to Aspergillus, a clinical syndrome known as allergic bronchopulmonary aspergillosis. Excessive production of mucus results in mucoid impaction in the larger bronchi, often appearing roentgenographically as branching spindle-shaped shadows. These plugs are expectorated, leaving dilated bronchi of the type seen in Figure 3 (arrow). The condition seems to be more common in England than in the US.'-' Pepys4 has suggested that atopic subjects become sensitized to Aspergillus and a dual type of hypersensitive response develops: type I (immediate) which is mediated by IgE (reaginic) antibodies, responsible for wheal and flare skin reaction, eosinophilia, and asthma; and type I11 (Arthus) which is mediated by IgG (precipitating) antibodies, responsible for delayed Arthus skin reaction, pulmonary infiltrates, bronchiectasis, and serum precipitins. The therapy for these patients include nystatin inhalation, primaricin aerosols, and corticosteroids. Some of these patients may recover spontaneously; in others extensive bronchiectasis and cor pulmonale super~ene.~ ACKNOWLEDGMENT: We are teful to Dr. J. Pep Brompton Hospital, London, ~ n g c d ,for estimating serum precipitin antibodies against Aspergillus.
1 Hinson KFW, Moon AJ, Plummer AS: Bronchopulmonary aspergillosis: a review and a report of 8 new cases. Thorax 73:317, 1952 2 Campbell MD, Clayton YM: Bronchopulmonary aspergillosis: a correlation of the clinical and laboratory findings in 272 patients investigated for bronchopulmonary aspergillosis. Am Rev Resp Dis 89:186. 1964 3 Edge JR, Stansfield D, Fletcher DE: Pulmonary aspergillosis in an unselected hospital population. Chest 59:407, 1971 4 Pepys J: Hypersensitivity diseases of the lungs due to fungi and organic dusts. Monographs in Allergy (vol 4, 1st ed) Basel, S Karger, 1969
CHEST, VOL. 65, NO. 1, JANUARY, 1974