1. Case summary – I 51 year old male CC: Chest tightness and blood tinged sputum for 12 months No fever, cough, dyspnea or weight changes Ex-Smoker PH: AR and sinusitis history, but no history of chronic asthma X-ray Pleural effusion, Left 9 months ago Pleural fluid: eosinophilia (21%), and exudate findings with high ADA level (65 U/L) Lab: ELISA for PW/CS : positive, peripheral eosinophilia: 800/mm3 Imp: Tuberculous pleurisy and pulmonary paragonimiasis Management: Ant-tbc medications and praziquantal for 3days

2. Follow up 1 month of anti-TB medication Still not resolved problems 1. Wheezing developed 2. Persistent left pleural effusion 3. Peripheral eosinophilia: 3300/mm³ ( from 808) 4. Persistent blood tinged sputum, but normal BFS 5. Normal nerve conduction velocity Imp) Churg-Strauss syndrome Start oral prednisolone 30 mg/d, but not-well-controlled

3. After 6 month of anti-TB medication Pleural effusion: improved Normalized blood eosinophil count-stopped steroid  Two months before the admission, recurred eosinophilia with increased pleural effusion developed

4. Case summary – II, problems on admission Recurred blood eosinophilia & pleural effusion No fever, crackle sound on chest Peripheral eosinophilia: 1660/mm3, serum total IgE: 500 IU/ml PFT: moderate obstruction pattern without bronchodilating response Chest X-ray: left pleural effusion, Chest C-T: mass like lesion

5. The key findings of this patient.. 1. Persistent peripheral eosinophilia 2. Pleural effusion with eosinophilic infiltration 3. Airway obstruction findings including wheezy episode, reversible with steroid treatment history of allergic rhinitis, sinusitis and asthma 4. Mass like lesion

6. Diagnosis suggested 1.Pulmonary paragonimiasis : Based on recurrent blood tinged sputum, pleural effusion with mass like lesion, persistent eosinophilia, but no history of crayfish or crab history, high ADA level in pleural fluid, failure to praziquantel treatment 2. Churg-Strauss syndrome : Commonly found asthma patients with eosinophilia 3. Malignancy : Mass like lesion with pleural effusion in 51-yr old male patient 4. TB granuloma : effusion, mass like lesion, high ADA level

7. Eosinophilia related diseases 1. Allergic diseases: severity related -asthma, AR, atopic dermatitis -asthma, AR, atopic dermatitis - ABPA - Churg-Strauss syndrome 2. Parasite infections: toxocara, Ansakiasis, Paragonimiasis 3. Drug induced 4. Malignancy : lympho- proliferative diseases

8. Paragonimiasis (1) Caused by the lung fluke, the trematode of the genus Paragonimus Clinical symptoms depend on the location and developmental stage of worms. Cough (62-100%), Hemoptysis (61-95%), Chest pain (38-94%) Pleuritic chest pain, Pneumotherax caused by penetration of larvae through diaphragm/pleura Pleural effusions typically eosinophilic with low glucose, low pH, and high LDH. (CSS is the only other disease that produces this constellation of pleural fluid findings)

9. Paragonimiasis (2) Radiologic findings pulmonary nodule pneumotherax interstitial infiltrates cavity formations ring cysts resembling bronchiectasis Pleural effusion (48-62%) – most common finding Parenchymal consolidation Treatment Praziquantel 25mg/kg tid for 2 days is effective in > 90% of cases

10. Diagnostic criteria of CSS American College of Rheumatology (1990) 1. Asthma 2. Eosinophilia>10%, 1500 > 3. Neuropathy, mononeuropathy, or polyneuropathy 4. Pulmonary infiltrates 5. Paranasal sinus abnormality 6. Extravascular eosinophil infiltration on biopsy finding Diagnosis when four of the six criteria are present From J Allergy Clin Immunol 2001;108:s1-19

11. Typical case of CSS 1.Long standing asthma and rhino-sinusitis ( > 5 yrs) - uncontrolled cases requiring daily medications 2.Lung parenchymal infiltration 3.Evidence of vasculitis involving nerve, skin, reticulo- endothelial systems 4.Remission of eosinophilia after stopping oral corticosteroid is very rare 5. Remission of asthma symptoms without any medications is very rare

12. Typical case of CSS

13. Lung cancer 1.Pleural effusion eosinophilia (>10%) is unusual in malignant effusion, but, 20% of eosinophilic effusions  malignant 20% of noneosinophilic effusions  malignant 2. Peripheral eosinophilia Eosinophilia occurs in patients who have lung cancer, more frequently associated with Hodgkin’s disease 3. No systemic symptoms suggesting malignancy, long standing symptoms, normal BFS and sputum result, PET finding– tissue biopsy was done… Chest 1996;110:1271-4

14. TB granuloma 1.No evidence of TB infection in sputum, pleural effusion and BFS 2.No eosinophils in pleural effusion or blood 3.Recurred pleural effusion after 6 months anti-TB medications 4.High ADA in pleural effusion 5.Positive PPD skin test 6.Positive Qunatiferon-TB GOLD test

15. Etiology known Parasite infestations (Tropical eosinophilia, Ascaris, Strongyloides stercoralis, others) Eosinophilic pneumonias of other infectious causes Allergic bronchopulmonary aspergillosis Drug, toxic agents, and radiation-induced eosinophilic pneumonias Eosinophilia-myalgia syndrome Idiopathic Loeffler’s syndrome Acute eosinophilic pneumonia Chronic eosinophilic pneumonia Churg-Strauss syndrome Hypereosinophilic syndrome Miscellaneous lung diseases with possible associated eosinophilia Organizing pneumonia Asthma and eosinophilic bronchitis Idiopathic interstitial pneumonias Langerhans cell granulomatosis Lung transplantation Other lung diseases with occasional eosinophilia Sarcoidosis Paraneoplastic eosinophilic pneumonia Murray and Nadel’s Textbook of respiratory medicine, 4 th, 2005 Classifications of the Eosinophilic Lung Diseases

16. ABPA : Asthma + eosinophilia 1.Long standing uncontrolled asthma 2.Sensitivity to Asp. fumigatus by skin test and high serum specific IgE 3.High serum total IgE level 4.Central type bronchiectasis 5.Precipitating antibody, IgG to Asp fumigatus

17. Acute and chronic eosinophilic pneumonia Drug induced, idiopathic, drug history, typical radiologic findings, evidence tissue eosinophilia in BAL and sputum

18. Impression 1.Pulmonary paragonimiasis Persistent blood tinged sputum, pleural effusion, persistent eosinophilia, granuloma formation 2. Malignancy, less likely