Case in Point
Another Reason Not to Smoke:
Acute Eosinophilic Pneumonia
Capt Jeffrey D. DellaVolpe, MD, MPH, USAF, MC; Doug Weinberg, MD; and Michael Landry, MD, MSc
Acute eosinophilic pneumonia is an uncommon but potentially
life-threatening cause of respiratory failure if left untreated.
The following case was en- countered and treated by Capt DellaVolpe during deploy- ment with Operation Enduring Freedom-Trans Sahara on his tour
as Special Operations Flight Surgeon
with the Air Force Special Operations
Command. The case highlights a rare
but serious disease that can be particularly challenging to manage in military members serving overseas.
After 2 days of worsening dyspnea
on exertion, fever, and fatigue, a
previously healthy 22-year-old man
presented to a remote clinic estab-
lished as part of a military deploy-
ment in central Africa. Despite
having received azithromycin from a
field medic, his condition continued
to worsen. He had no cough, recent
weight changes, or night sweats. The
patient’s past medical history was un-
remarkable, including any prior his-
tory of pulmonary disorders.
The patient was a member of the
U.S. Army Military Police Corps
and had been deployed for 3 weeks.
His job involved local patrols, and
he had no history of airborne exposures, such as mold or chemical
inhalants, or travel to sandy environments. Although he was previously
a nonsmoker, he reported smoking local cigarettes to help him stay
awake during night patrols over the
past 2 weeks. The patient’s vaccination history included influenza, tetanus, measles/mumps/rubella, yellow
fever, typhoid, hepatitis A/B, anthrax,
meningococcus, and smallpox, all
administered before deployment. At
the time of evaluation, his temperature was 103.9°F, pulse 120 bpm, respiratory rate 32 breaths per minute,
and blood pressure 110/70 mm Hg.
His oxygen saturation was 80% on
On examination, he was in significant distress and only able to speak in
short sentences. There was no jugular
venous distension or stridor. He was
tachycardic, with a regular rhythm,
without murmurs, rubs, or gallops.
A pulmonary examination revealed
decreased air movement bilaterally
with bilateral inspiratory crackles at
the bases. There was a tactile fremitus
on the right side. He had no swelling
or tenderness of the extremities, and
no rashes were noted.
Laboratory capabilities were
limited given the remote clinic
location. Rapid malaria and rapid
influenza were negative. A blood
smear showed no organisms. A chest
X-ray showed diffuse alveolar infiltrates and homogenous opacification
of the right hemithorax.
The patient was placed on continuous oxygen by facemask and started
on IV ceftriaxone and vancomycin.
He was volume resuscitated with normal saline, with a modest effect on his
heart rate. Attempts to wean his oxygen consumption were accompanied
by an immediate oxygen desaturation
to the low 80s. Because of the limited
supply of oxygen available at the remote location as well as the patient’s
poor response to broad-spectrum
antibiotic coverage over the next
8 hours, he was evacuated by airborne casualty evacuation to the critical care team at Landstuhl Regional
Medical Center in Germany.
Laboratory results revealed a peripheral leukocytosis with no eosinophilia. The patient underwent
bronchoalveolar lavage (BAL), which
showed 30% eosinophils. A diagnosis of acute eosinophilic pneumonia
Capt DellaVolpe is a member of the US Air Force
and a critical care medicine fellow at the University of
Pittsburgh Medical Center in Pennsylvania. Dr. Weinberg is an orthopedic surgery resident at Case Western Reserve University in Cleveland, Ohio. Dr. Landry
is the chief of medicine and chief of general internal
medicine at the Southeast Louisiana Veterans Healthcare System and is an associate professor of internal
medicine and pediatrics at Tulane University School of
Medicine, both in New Orleans, Louisiana.