Abstract Introduction Daptomycin induced eosinophilic pneumonia (DIEP) is a rare but serious adverse event requiring urgent clinical intervention. Daptomycin use has gained popularity due to its broad spectrum in treating various gram-positive/negative organisms, strong safety profile, and once daily dosing, which makes it ideal for long-term outpatient therapy. DIEP typically presents within two to four weeks of therapy with progressive dyspnea, hypoxia, BAL/peripheral eosinophilia, and new pulmonary infiltrates on x-ray/CT. Diagnosis is challenging as symptoms are similar to commonly encountered systemic diseases and respiratory infections. Case report A 66-year-old male with multiple comorbidities and chronic lymphocytic leukemia (CLL) on chemotherapy presented with progressively worsening shortness of breath without cough, fever, or chills after being recently discharged from the hospital. He had a transmetatarsal amputation for osteomyelitis 24 days ago, with wound cultures growing coagulase-negative staph and Enterococcus faecalis, and was discharged with a six-week course of IV daptomycin. He was admitted to the ICU due to his requirement for constant non-invasive Biphasic ventilation. Labs were significant for leukocytosis without eosinophilia. A chest CT showed new-onset ground-glass opacities, concerning for pneumonia. IV daptomycin was discontinued on day 1 after admission due to a strong suspicion of DIEP. The patient was started on methylprednisolone 60mg IV every 6 hours and empiric antibiotics. Further workups, including blood cultures, cryptococcus antigen, histoplasma antigen, respiratory infectious serology (rhinovirus PCR positive), and galactomannan assay were negative. He made a rapid recovery with these interventions, including aggressive physical therapy and was weaned off high supplemental oxygen. On day 18, the patient was discharged home on 2L home oxygen via nasal cannula and oral prednisone. Discussion According to the diagnostic criteria proposed by the U.S. Food and Drug Administration, DIEP should be suspected in patients who develop eosinophilia in bronchoalveolar lavage (BAL) fluid 25% or peripheral eosinophilia in addition to the typical symptoms and presence of daptomycin as an inciting factor. In our patient, peripheral eosinophilia was notably absent, and initially BAL could not be performed given severe hypoxia on presentation. In cases such as this, DIEP can be considered a “possible” diagnosis, according to the literature. The strong temporal association between symptom onset and daptomycin initiation, characteristic radiologic findings, and rapid improvement after steroid therapy collectively supported the diagnosis of DIEP. This case highlights the unique challenge posed by immunocompromised patients with DIEP, who may not exhibit eosinophilia on peripheral blood and BAL. This abstract is funded by: None
Zafar et al. (Fri,) studied this question.
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