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Page 6 / Case 02.03

ANSWER

For evaluation of a child with pulmonary infiltrates, peripheral eosinophilia is a valuable diagnostic guide. It focuses the differential on a group of conditions grouped under the term - Pulmonary infiltrates with eosinophilia syndromes or PIE. This classification was first devised by Crofton in 1952 and presented here in modified format designed by Schatz et al.

The differential includes the following:
– Allergic Bronchopulmonary Aspergillosis (APBA)
– Chronic Eosinophilic Pneumonia (CEP)
– Neoplasm e.g. Hodgkin's disease
– Immunologic disorder
– Drug reaction
– Hypereosinophilic syndrome
– Allergic bronchopulmonary helminthiasis
– Vasculitis( Churg-Strauss Syndrome)
– Toxic Oil Poisoning

Many of these diagnoses can be excluded based on history or examination. There is no history of drug ingestion. Pulmonary infiltrates with eosinophilia can occur in association with immunological conditions such as rheumatoid arthritis but there is no evidence of this condition. There is no history of foreign travel and no exposure to animals so parasitic infection is unlikely. Toxic oil poisoning was found in Spain in the 1980's in association with contaminated olive oil so this is unlikely. Hypereosinophilic syndrome can be excluded on the basis of the short duration of the illness and the higher degree of eosinophilia which is usually seen with this condition. There is evidence to support Hodgkin's disease. Churg Strauss is a multi-organ vasculitis in which allergic rhinitis, reactive airways disease occur in association with marked peripheral eosinophilia which is not the spectrum in this patient.

The following differentials remain and need to be thoroughly investigated:
(1) APBA
(2) Infection
(3) CEP
(4) Hypersensitivity Pneumonitis Question

WHAT INVESTIGATIONS WOULD YOU CARRY OUT ON THIS PATIENT?


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