# 2021/09/22 Clinical problem solver episode 178: Pulmonary disease and eosinophilia schema
## [Episode 178: Pulmonary disease and eosinophilia schema](https://clinicalproblemsolving.com/2021/05/27/schema-episode-pulmonary-disease-and-eosinophilia/)
### In ER
59 y/o female with a history of recent motorbike accident related quadriplegia and brain injury s/p Tracheotomy with O2 demeand of 2L presented with desaturation.
#### S: She couldn't talk
#### O:
SpO2 84, HR 130, RR 30. WBC(N), PCT 1.046, COVID(-), CXR: RUL opacity.
12hrs later: WBC 10.7, Differential count(N), F/U CXR concerned progressive RUL opacity.
#### A:
No improvement after suction. Desaturation relieved with O2 8L(FiO2 40%), but 12hrs later, O2 demands increased to 10L(40%) with leukocytosis and progressive CXR opacity
#### P:
Vancomycin and Zosyn(Tazocin in Taiwan) for suspected aspiration pneumonia. For MRSA and pseudomonas due to recent hospitalization.

### 24 hours later
TPR: 39.1/107/30, BP(N), SpO2 80
Increased work of breathing

### *Teaching 1*
Hypoxemic respiratory failure
1. Alveoli: Collapse(Atelectasis, Mucus, Pleural effusion, Diaphragm), Filled(pus, water, blood, protein), Loss(Emphysema)
2. Vessel: PE, Shunt

CXR: filled alveolar pattern with antibiotics treatment failure

### 24 hours later
1. CXR: RUL opacity increased and diffuse bil. GGO with infiltration
2. VBG: pH 7.49, CO2 32. Lactate 3.6, WBC 11.9
3. Atypical panel(-), Respiratory panel(-), MRSA swab(-), B/C(-), Treacheal aspirate gram stain > 100k

### *Teaching 2*
Antibiotics failure
1. Wrong diagnosis: Non-bacterial infection? Drug induced? Malignancy?
2. Wrong anti: Tissue peneration? Resistance?
3. Too early in the course: aggressive infection like MRSA
4. Treaheal aspirate: colonized or true pathogen?

### 12 hours after -> send to ICU
Fever sustained for 12 hours
Increased O2 demand to 10L(50%)
Hypotension -> required Levophed

ABG pH 7.47, pCO2 36, PaO2 52
CXR: worsen diffuse opacity
WBC 17k (eos 1100)
BAL: pink, WBC 1711(36% eos), 7500 RBC, culture(-)

### *Teaching 3*
Eosinophilia: consider the organs in contact with environment: Skin, Lung, GI, and Heart(?)
1. Primary Leukemia, hyper eos syndrome
2. Secondary: allergy to drug. Hypersensitivity pneumonitis, pulmonary aspergillosis
3. Infection: other than bacteria and virus
4. Lymphoma and cancer: organs in contact with environment

Antibiotic failure
1. Far away from diagnosis: Not infection
2. Close but not quite: partial treatment, immunocompromise pt, anti-resistant
3. Complication

Eosinophilia: Atopy and drug!!!

### Final diagnosis
Pipercillin induced acute eosinophilic pneumonia.
She had skin rash and pneumonitis reaction with Zosym in the past, but hadn't be recorded.

### Reflection
#### 學習到評估antibiotics failure的方法
1. 如果是診斷錯誤，臨床症狀完全不會改善。考慮細菌以外的病原體感染、抗生素副作用、自體免疫，以及癌症。
2. 可能是治療效果不佳，此時臨床症狀可能會些微改善。考慮Anti的選擇不佳(Tissue peneration, resistance, immunocompromised)
3. 也可能是疾病的自然進程，本就不會那麼快緩解

#### 學習到Eosinophilia的評估
口訣: Atopy and drug! 最常見的是各種過敏
考慮到會和環境接觸的器官(Skin, Lung, GI)和心臟，除了細菌病毒外的感染，還有癌症。
-> 問診別忘了問藥物過敏XD