Eosinophilic pleuritis due to propylthiouracil

Carbimazole-induced eosinophilic pleural effusion

We report the case of a 41-year-old woman who presented with a unilateral exudative effusion with prominent eosinophils on pleural cytology. Carbimazole had been started 4 weeks prior to presentation. No immediate cause was identified on imaging or laboratory testing. The effusion persisted at 2-month follow-up. Further investigation at this time, including autoimmune serology was negative. At 2-month follow-up, the effusion was loculated on ultrasound imaging and had a low fluid pH on diagnostic aspiration, in keeping with an empyema. The patient received treatment for pleural empyema, including antibiotics, intercostal drain insertion and video-assisted thoracoscopic pleural biopsy. Carbimazole was stopped, and following treatment for the empyema, the effusion did not reaccumulate.This case illustrates the diagnostic difficulties that pleural effusions may present. It demonstrates that drug reactions should be considered in the differential diagnosis following thorough investigation for other potential causes and also describes the complications that may occur.

Methimazole associated eosinophilic pleural effusion: a case report

Background

Adverse reactions associated to anti-thyroid drugs include fever, rash, arthralgia, agranulocytosis and hepatitis that are thought to be hypersensitivity reactions. Five cases of pleural effusion associated to thionamides have also been reported, two with propylthiouracil and three with carbimazole.

Case presentation

We report here a case of a 75-year-old man admitted because of unilateral pleural effusion. The patient had a recent diagnosis of hyperthyroidism and 6 days after starting methimazole complained of pleuritic chest pain. He had elevated C-reactive protein and erythrocyte sedimentation rate and normal white blood cell count and liver enzymes. Chest radiography showed a moderate right pleural effusion and the ultrasound revealed a loculated effusion that was shown to be an eosinophilic exudate.

Conclusions

The temporal relationship between methimazole intake and the development of pleural effusion combined with the extensive exclusion of alternative causes, namely infectious, neoplastic and primary auto-immune diseases, led to the diagnosis of hypersensitivity reaction to methimazole. The thionamide was stopped and corticosteroid was started with complete resolution of the pleural effusion in 3 months.

Awareness of this rare adverse reaction of anti-thyroid drugs is important and methimazole can be added to the list of possible etiologies of drug-induced eosinophilic pleural effusion.

Carbimazole induced pleural effusion: a case report

Objective. To describe a patient with unilateral exudative pleural effusion that developed after commencement of carbimazole. Methods. We describe the presentation and clinical journey of an elderly woman who presented to the chest physicians initially with pleural effusion but was followed up by the endocrinology team. Result. The patient was a 77-year-old Caucasian woman who presented with symptoms of breathlessness and a confirmed unilateral pleural effusion while being on treatment for thyrotoxicosis. Her symptoms needed recurrent hospital admission for investigations and drainage, but no potential cause was identified after extensive investigations. A drug-induced exudative effusion consequent to carbimazole intake was diagnosed as discontinuation of the drug lead to complete resolution of the effusion with no recurrence. Conclusion. Physicians and Endocrinologist must bear in mind that this potentially rare complication of carbimazole while treating patients of thyrotoxicosis as appearance of similar features in their patients while being on carbimazole should lead to the discontinuation of the drug, and alternative treatment strategy should be considered.

Idiopathic lymphocytic pleuritis: radiographic and high-resolution CT appearances and changes in response to therapy in two adults

Inflammatory conditions of the pleura characterized by a predominantly lymphocytic infiltrate are described in several disorders. The commonest underlying aetiologies include tuberculous infection, autoimmune disorders (particularly Sjogren's syndrome), and post coronary artery bypass graft surgery. Idiopathic lymphocytic pleuritis (ILP) is a rare form of diffuse pleural inflammation characterized by extensive lymphocytic infiltration for which no cause is found. Radiological descriptions of ILP are limited. We describe the radiographic and high-resolution computed tomography (HRCT) imaging features and response to corticosteroid therapy of ILP in two adults. Both patients presented with bilateral diffuse pleural thickening of >10 mm thickness extending >10 cm craniocaudally with small focal areas of atelectasis. Both cases demonstrated marked improvement in the degree and extent of pleural thickening and rounded atelectasis following corticosteroid therapy. HRCT provided a useful noninvasive method of assessing disease response to therapy.

Massive eosinophilic pleural effusion preceding vasculitic symptoms in Churg-Strauss syndrome

We report a case of Churg-Strauss syndrome (CSS) presenting as a massive pleural effusion. A 52-year-old asthmatic Japanese woman presented with progressive dyspnea caused by an eosinophilic pleural effusion (EPE). She also had chronic sinusitis, skin lesions and blood eosinophilia, but no antineutrophil cytoplasmic antibodies. Skin biopsy and the late onset of mononeuritis multiplex led to the diagnosis of CSS. The pleural effusion resolved soon after corticosteroid treatment was started. CSS is rare as a cause of EPE, but should be included in the differential diagnosis of EPE in asthmatic patients. This is the first report showing that EPE can precede other vasculitic symptoms in CSS.

Hydatid cyst presenting as an eosinophilic pleural effusion

A 61-year-old woman presented with an eosinophilic pleural effusion, secondary to transdiaphragmatic intrapleural spread of an hepatic hydatid cyst. Right posterolateral thoracotomy and frenotomy revealed a loculated pleural effusion associated with a 10 x 8 cm hydatid cyst in the posterior segment of the liver. Hydatid disease should be included in the differential diagnosis of eosinophilic pleural effusions in endemic regions.

Valproic acid-induced eosinophilic pleural effusion: a case report and review of the literature

OBJECTIVE

To report a case of valproic acid-induced eosinophilic pleural effusion and to review the existing literature.

CASE SUMMARY

A 25-year-old African-American man receiving valproic acid, 250 mg/d, had a moderate-sized right pleural effusion. Pleural fluid analysis revealed 75% eosinophils. The patient had no evidence of parasitic infection, hemothorax, or pneumothorax. One month after valproic acid was discontinued, there was no evidence of a pleural effusion by both chest radiography and thoracic ultrasonography.

DISCUSSION

Valproic acid-induced pleural effusions have been reported in the medical literature in 5 case reports. Pleural fluid eosinophilia is almost always related to pneumothorax, hemothorax, parasitic infection, or drug toxicity; therefore, when the first 3 causes have been eliminated, a drug should be suspected. Only a few medications are known to cause pleural fluid eosinophilia, one being valproic acid. The Naranjo probability scale rated this adverse reaction as probably drug-related.

CONCLUSIONS

In all 6 patients discussed in this review, the pleural effusions resolved after discontinuation of the valproic acid. None of these patients had associated pulmonary infiltrates. Valproic acid eosinophilia may be associated with peripheral blood eosinophilia. Valproic acid should be added to the list of medications that can cause an eosinophilic pleural effusion.

Propylthiouracil-Associated Eosinophilic Pleural Effusion: A Case Report

We describe an unusual case of a patient with eosinophilic pleural effusion (EPE) associated with long-term propylthiouracil (PTU) administration. A 43-year-old woman was admitted to our hospital after complaining of chest pain. She had had Graves' disease, which had been treated with PTU for 11 years. Right-sided pleural effusion was detected and the result of thoracentesis confirmed an EPE. The patient's detailed medical evaluation failed to reveal any other cause of EPE. PTU was terminated since it was thought to be the cause. Despite withdrawal of the medication, however, the pleural effusion persisted for 6 weeks, and steroid therapy was planned for 15 days in decreasing dosages. During the control visit 10 days after the initiation of steroid therapy, no pleural effusion was observed, and the steroid was discontinued. Rechallenge with PTU produced recurrent pleural effusion. Therapy with PTU was again terminated, and treatment with methimazole and a brief course of low-dose corticosteroids were begun. Chest radiography revealed disappearance of the effusion within 10 days and it did not recur during a 1-year follow-up. To our knowledge, there is only 1 other case in the English-language literature describing EPE caused by PTU. Our report is of particular importance because it describes the development of that disorder in the 11th year of PTU treatment. It also shows that steroid therapy can be effective in treating drug-induced EPE.

Pleural fluid and peripheral eosinophilia from hemothorax: hypothesis of the pathogenesis of EPE in hemothorax and pneumothorax

Blood and air in the pleural space are the most common conditions associated with an eosinophilic pleural effusion. The recruitment of eosinophils is dependent upon stimulation by cytokines, specifically interleukin (IL)-3, IL-5, granulocyte-monocyte cell stimulating factor (GM-CSF), and RANTES (regulated upon activation, normal t-cell expressed and secreted), that cause eosinophil proliferation in the bone marrow, movement into the circulation, and adhesion and migration across endothelial barriers into tissues. There are several possible mechanisms that can explain eosinophilic pleural effusions. We report a case of an eosinophilic pleural effusion after spontaneous hemothorax that illustrates the course of pleural fluid and blood eosinophilia in following hemothorax and describe the different pathophysiology of eosinophil trafficking in the pleural space and serum following hemothorax and pneumothorax.

Imidapril-Induced Eosinophilic Pleurisy

We describe an unusual case of a patient with eosinophilic pleurisy associated with long-term administration of imidapril, an angiotensin-converting enzyme inhibitor (ACEI). An 81-year-old woman who had been given imidapril for the treatment of essential hypertension was admitted to our hospital for investigation of persistent low-grade fever, dry cough and difficulty in breathing. Left-sided eosinophilic pleurisy was diagnosed based on eosinophilic pleural effusion and peripheral eosinophilia. Soon after administration of imidapril was discontinued, her clinical symptoms subsided, and there was improvement in both diagnostic imaging and laboratory findings. So far, to our knowledge, this is the first reported case in which ACEI induced eosinophilic pleurisy.

Drug-induced eosinophilic lung disease

For most patients who have suspected drug-induced eosinophilic lung disease, the history provides a presumptive diagnosis that can be confirmed by pulmonary findings and eosinophilia after cessation of the drug. As new drugs are developed and released for clinical use, many will result in eosinophilic lung disease in susceptible patients. Therefore, development of pulmonary abnormalities in conjunction with blood or lung eosinophilia after prescription ofa newly released medication should raise the possibility of drug-induced lung disease, even if that medication has not yet been reported to cause eosinophilic lung disease. In all patients, the diagnosis requires exclusion of other causes of eosinophilic lung disease by history, and, if necessary, laboratory testing or lung biopsy.

Drug-induced pleural disease

Drug-induced pleural disease is uncommon and less known to clinicians than drug-induced parenchymal lung disease. Pleural reactions from drugs manifest as pleural effusions, pleural thickening, or pleuritic chest pain, and may occur in the absence of parenchymal infiltrates. The clinician should be cognizant of the possibility of a drug-induced pleural reaction. A detailed drug history, temporal relationship between symptom onset and initiation of therapy, and pleural fluid eosinophilia should raise the suspicion of a drug-related process. We suspect that as new drugs are marketed in the United States, the number of drugs that result in pleuropulmonary toxicity will continue to increase. Moreover, if the cause of an exudative pleural effusion is not clinically obvious after pleural fluid analysis, drug therapy withdrawal should be a consideration if clinically appropriate before initiating an extensive diagnostic evaluation that may entail unnecessary economic burden and discomfort for the patient.

Eosinophilic pleural effusions

Eosinophilic pleural effusions, defined as a pleural effusion that contains at least 10% eosinophils, may be caused by almost every condition that can cause pleural disease. Eosinophilic pleural effusion occurs most commonly during conditions associated with the presence of blood or air in the pleural space, infections, and malignancy. Drug-induced pleural effusions, pleural effusions accompanying pulmonary embolism, and benign asbestos pleural effusions are also among the common causes of eosinophilic pleural effusion. No etiology is found in as many as one third of patients. Because studies evaluating different diagnostic approaches with eosinophilic pleural effusions are lacking, the authors suggest that certain noninvasive and invasive diagnostic tools must be used based on the patient's clinical characteristics.

Cutaneous and systemic manifestations of drug-induced vasculitis

OBJECTIVE

To evaluate the literature for published cases of drug-induced vasculitis with cutaneous and/or systemic manifestations.

DATA SOURCES

The MEDLINE database was searched from 1965 to December 1999 for articles focusing on drugs and vasculitis, using various search terminologies (e.g., Churg-Strauss syndrome, Goodpasture's syndrome, Henoch-Schönlein purpura, various drugs suspected to induce vasculitis). Cases were included when they met the established criteria as described in the methodology.

DATA SYNTHESIS

Drugs found to be most frequently associated with vasculitis were propylthiouracil, hydralazine, colony-stimulating factors, allopurinol, cefaclor, minocycline, D-penicillamine, phenytoin, isotretinoin, and methotrexate. The interval between the first exposure and appearance of symptoms was reported to be extremely variable (hours to years). Vasculitis has occurred after drug dosage increases and after rechallenge with the suspected drug. In the majority of cases, vasculitis has resolved after discontinuing the drug. Patients with more severe, often life-threatening, manifestations have required treatment with corticosteroids, plasmapheresis, hemodialysis, or cyclophosphamide. Death was the result in 10% of all published cases, with a predominance in patients in whom multiple organ systems were involved.

CONCLUSIONS

Clinicians need to be suspect of drug-induced vasculitis to enable prompt diagnosis and treatment. This should improve patient outcomes based on the data referenced for this article.

Life-threatening eosinophilic pleuropericardial effusion related to vitamins B5 and H

OBJECTIVE

To report a case of eosinophilic pleuropericarditis resulting from concomitant use of vitamins B5 and H.

CASE SUMMARY

A 76-year-old white woman was admitted to the hospital because of chest pain and dyspnea related to pleurisy and a pericardial tamponade. This patient had no history of allergy and had been taking vitamins B5 and H for two months. Blood tests performed showed an inflammatory syndrome and a high eosinophil concentration (1200-1500 cells/mm3). Pleurocentesis and pericardiotomy yielded a sterile exudative fluid with an eosinophilic infiltrate. There were no nuclear antibodies and no rheumatic factor; screenings for viruses, parasites, bacteria, and malignant tumor were negative. A myelogram, biopsy of the iliac crest bone, and concentration of immunoglobulin E were also normal. After withdrawal of the vitamins, the patient recovered and the eosinophilia disappeared.

DISCUSSION

Prolonged hypereosinophilia has marked predilection to damage specific organs, including the heart, but pleuropericardial effusion is uncommon. Drug-related pleuropericarditis usually occurs without an increased eosinophil count. Other drugs responsible for eosinophilic pleuropericarditis are cephalosporins, dantrolene, propylthiouracil, and nitrofurantoin. To our knowledge, this is the first case report of pleuropericarditis related to vitamins B5 and H.

CONCLUSIONS

This case suggests that vitamins B5 and H may cause symptomatic, life-threatening, eosinophilic pleuropericarditis. Physicians prescribing these commonly used vitamins should be aware of this potential adverse reaction.

Drugs and the pleura

PURPOSE

To identify the drugs associated with pleural disease and to review the clinical, radiographic, and pleural fluid findings that occur, the natural history of the pleural reaction, and the response to therapy.

DATA SOURCES

English-language articles published from January 1966 through April 1998 were identified through searches of the MEDLINE database, selective bibliographies, and personal files.

DATA EXTRACTION

Case reports, letters, and review articles were assessed for relevancy. Reports of drug-associated pleural effusion, pleuritis, and/or pleural thickening were analyzed. Drug effect was believed to be causal when exposure induced pleural disease, when the pleural response remitted on discontinuation of the drug, and when the pleural disease recurred with reexposure. Drug association was inferred when the pleural disease occurred following drug exposure and remitted after drug discontinuation. The incidence, clinical presentation, dose and duration of drug therapy, chest radiographic findings, pleural fluid analysis, and response to therapy were recorded.

CONCLUSIONS

A relatively small number of drugs were found to induce pleural disease when compared to the number of drugs implicated in causing disease of the lung parenchyma. Treatment of drug-induced pleural disease consists of drug therapy withdrawal and corticosteroids for refractory cases. Knowledge of the potential of drug-induced pleural disease will provide a clinical advantage to the physician and should lead to decreased morbidity and economic burden for the patient by avoidance of further diagnostic testing.

An Antineutrophil Cytoplasmic Autoantibody Associated with a Propylthiouracil-Induced adult Respiratory Distress-Like Syndrome: Report of a Case and Review of the Literature

OBJECTIVE

To report the first case of propylthiouracil-induced adult respiratory distress-like syndrome associated with the presence of an antineutrophil cytoplasmic autoantibody.

METHODS

We describe the initial manifestations, laboratory findings, and clinical course in a patient and discuss underlying factors potentially contributing to her condition.

RESULTS

A 57-year-old woman with hyperthyroidism had an influenza-like illness and vasculitis during propylthiouracil therapy. Three days after she was admitted to the hospital, an adult respiratory distress-like syndrome developed. Results of perinuclear antineutrophil cytoplasmic antibody (pANCA) and antimyeloperoxidase antibody studies were positive. Her condition improved after the introduction of glucocorticoid therapy and the withdrawal of propylthiouracil treatment. The pANCA level, however, remained unchanged 3 months after her dismissal from the hospital.

CONCLUSION

The propylthiouracil-induced adult respiratory distress-like syndrome may be a hypersensitivity phenomenon, and the presence of the pANCA could be a marker of a common mechanism of injury that stimulates its production rather than a pathogenic factor responsible for vascular injury in our patient.