LIVING WITH IT WORKING WITH IT TREATING IT
A 17 year-old, previously-healthy female presented with six months of nasal congestion and cough, which would intermittently become productive of yellow-green sputum every few weeks. She had used beclomethasone and albuterol without significant improvement. This previously-athletic adolescent reported progressive dyspnea sometimes provoked even by crossing the street. She also had fatigue and unintentional weight loss of several pounds. She was referred to infectious disease clinic after a chest radiograph and subsequent computed tomography (CT) of the chest revealed a 3 x 4 cm ground-glass opacity in the left upper lobe interpreted as a possible cavitary lesion. A variety of patchy ground-glass opacities were also noted throughout the periphery of both lungs. Our pediatric pulmonology service was consulted in order to obtain a bronchoalveolar lavage. The patient did live near active construction sites in a coccidiodesimmitis-endemic area. Additionally, the patient endorsed smoking combustible marijuana products 4-5 times per week. She reported trying vaping intermittently. A complete blood count revealed leukocytosis with an absolute eosinophil count of 15.26 K/uL. Additionally, the serum total IgE was high at 1,034 kU/L. Laboratory work-up for HIV, coccidiodomycosis, mycobacteria, parasites (including toxocara and trichinella), histoplasma, aspergillus, and ANCA vasculitides was negative. Flexible bronchoscopy revealed normal airway structure with hyperemic mucosa and increased, white secretions, particularly in the right upper and lower lobes. Lavage fluid had an elevated white blood cell count of 1,506 cells/mm3 with an eosinophilic predominance of 65%. Respiratory cultures were unremarkable. Cytopathology showed macrophages and eosinophils without evidence of micro-organisms or malignancy. Initial pulmonary function testing (PFTs) revealed no restrictive disease (TLC 135% predicted), minimal obstructive disease (FEV1/FVC 78%), an insignificant response to bronchodilator challenge, a normal distribution of ventilation, and a low diffusing capacity (DLCO/VA 3.8 mL/mHg/min/L). The patient was diagnosed with a chronic eosinophilic pneumonia (CEP) and was started on prednisone 60 mg/day. She was counseled extensively regarding smoking cessation. At follow-up one month after discharge, she had markedly improved symptoms, and her diffusing capacity had normalized to 4.56 mL/mHg/min/L. Her chest radiograph cleared completely, her eosinophilia resolved, and her high IgE improved. At ~4.5 months post-diagnosis, she had been weaned to 30 mg/day of prednisone without complication and continued to have stable PFT results (TLC 132% predicted, FEV1/FVC 77%, and DLCO/VA 4.23 mL/mHg/min/L). CEPs appear to be extremely rare in pediatrics. The few reported marijuana-associated cases have been acute rather than chronic eosinophilic pneumonias, making our patient quite unique.
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