Abstract Acute Eosinophilic Pneumonia (AEP) is characterized by an acute decompensation in respiratory status, chest radiograph/CT findings of pulmonary infiltrate, and bronchoalveolar lavage (BAL) eosinophilia (15-25%). Although a rare manifestation, one common culprit is Daptomycin. The pathophysiology isn’t well understood, although, it is believed that because of daptomycin binding pulmonary surfactant, a cascade of cellular damage, lung epithelial inflammation, and activation of T-cells and interleukins play a role in the recruitment of eosinophils to the damaged lung tissue. The most effective overall proven treatment is prompt cessation of exposure to the offending agent. A 68-year-old female presented to the ED with progressive dyspnea and fatigue without fever or neutropenia. She had a cervical laminectomy complicated by MRSA infection two months prior. She was discharged home on IV daptomycin and ertapenem, for a total of 6 weeks of therapy. Just 7 days prior to the completion of her treatment, the patient’s symptoms began. On arrival, the patients’ vitals were stable. Laboratory evaluation revealed CRP 253, ESR 70, and peripheral eosinophils 510. CXR revealed multifocal reticular airspace disease, concerning for pneumonia. CTA PE demonstrated bilateral extensive coarse interstitial and ground-glass parenchymal densities. She was started on vancomycin and meropenem while inpatient, and due to concerns for daptomycin induced lung injury, bronchoscopy with BAL of the RLL and LUL was performed. This was significant for nearly 9% and 14% eosinophils, respectively. Given her mild symptoms and low degree of peripheral and alveolar eosinophilia, she was managed without steroids, and the offending agent was stopped. After 3 days, the patient’s respiratory status and symptoms greatly improved and she was discharged. Follow up CT scan 5 weeks later revealed marked improvement, and PFT 2 months post hospitalization was normal. Daptomycin induced AEP may present itself within 3 days and up to 6 weeks after exposure, with the majority of cases presenting between week 2-3. This patient’s presentation was closer to 6 weeks, classifying her presentation as late onset. Although this patient displayed mild symptomatology and lesser degree of peripheral and alveolar eosinophilia (500 and 9%-14%), her prompt resolution of symptoms immediately after discontinuing daptomycin made this diagnosis most likely. This case prompts the question of whether delayed presence/ absence of peripheral blood eosinophilia and lesser degree of BAL eosinophilia should delay the definite diagnosis of AEP when parameters such as chest radiographs/CT findings, known causative agent exposure, and resolution of symptoms after culprit withdrawal are present. This abstract is funded by: None
Fawaz et al. (Fri,) studied this question.