A 31‐year‐old Mexican male migrant worker was admitted with 7 months of gradually worsening cough, hemoptysis, night sweats, fevers, and weight loss. Physical exam revealed bilateral upper‐lobe wheezing and rhonchi. Chest x‐ray showed bilateral upper‐lobe infiltrates. Chest CT confirmed upper‐lobe consolidation with hilar adenopathy. A complete blood count revealed leukocytosis of 19,000 and elevated eosinophils. Infectious disease consultants suspected tuberculosis (TB). A protein purified derivative (PPD) was placed. Isoniazid, rifampin, pyrazinamide, and ethambutol were started, and isolation was instituted. Fevers and leukocytosis persisted, and a violaceous rash erupted on the patient's ankles. PPD, bronchoscopy sputum, and lung biopsy specimens were all negative for TB. Pathology review of the lung biopsy showed a dense eosinophilic infiltrate, whereas the skin biopsy revealed a leukocytoclastic vasculitis with prominent eosinophilia. C‐ANCA and P‐ANCA were negative. Chronic eosinophilic pneumonia was diagnosed, and steroids were started. The rash resolved. A prolonged 6‐month course of prednisone resulted in near‐complete resolution of symptoms and radio‐graphic findings.
Chronic eosinophilic pneumonia is rare and can be a difficult diagnosis to make, particularly when the patient's constellation of symptoms and signs are so consistent with pulmonary tuberculosis. In addition, the ankle rash suggested possible Churg‐Strauss syndrome but was likely secondary to a reaction from the anti‐TB medications, resulting in further delays in diagnosis and appropriate treatment. Peripheral eosinophilia was the single laboratory abnormality that is so rarely seen in TB that alternative diagnoses were sought. Persistence in demanding an explanation for the eosinophilia ultimately resulted in invasive testing that clinched the diagnosis of chronic eosinophilic pneumonia. Many disease entities can present with pulmonary infiltrates and eosinophilia. Table 1 lists some of these diseases and their differentiating features.
This case emphasizes the importance of considering every laboratory abnormality in developing a differential diagnosis for pulmonary infiltrates. Although TB is considered the great masquerader, in this case, chronic eosinophilic pneumonia masqueraded as the great mas‐querader, resulting in delays in diagnosis and treatment.
S. Raffee ‐ none; T. Tassava ‐ none
To cite this abstract:Raffee S, Tassava T. The Great Masquerader Strikes Again?. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 375. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/the-great-masquerader-strikes-again/. Accessed January 28, 2020.