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CLINICAL CASE

CLINICAL CASE. Eva Padrão, vanessa santos, patrícia Caetano mota, natália melo, conceição Souto Moura, Susana guimarães , josé pereira, rui cunha, antónio morais Porto, 25 february 2014. identification. JFSM Male gender 63 years-old Caucasian Resident in Maia

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CLINICAL CASE

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  1. CLINICAL CASE Eva Padrão, vanessa santos, patrícia Caetano mota, natália melo, conceição Souto Moura, Susana guimarães, josé pereira, rui cunha, antónio morais Porto, 25 february 2014

  2. identification • JFSM • Male gender • 63 years-old • Caucasian • Resident in Maia • Retired (occupation: glass fitter)

  3. Past medical history • Hypertension • Dyslipidemia • Esophageal hiatus hernia • Surgery to left knee bursitis in 2010 • Smoker (25 pack-years) • Allergy to ibuprofen; no other allergies documented • No drugs or alcohol consume; no sexual risk behaviours; no recent traveling abroad

  4. usual medication • Losartan/hydrochlorothiazide 50/12.5 mg id • Fenofibrate 200 mg id Note: • Fenofibrate(initiated in September 2013) was suspended by patient initiative for some time due to development of skin reaction • Meanwhile, administration was resumed two weeks before seeking medical assistance

  5. Main complaints • Fever • Myalgia • maculopapularrash

  6. History of present illness • At the beginning of October 2013 • fever, myalgia and sweating • medicated with amoxicillin/clavulanic acid and, subsequently, levofloxacin • 2 weeks later • maintenance of complaints + appearance of skin rash on the trunk and limbs • hospitalized for monitoring and antibiotic treatment (usual medication stopped during this period) • discharged 8 days later with a diagnosis of community-acquired pneumonia

  7. History of present illness Chest X-ray by the time of admission, with left perihilar opacity and amicronodular pattern at the right lung base.

  8. History of present illness • 3 daysafter discharge • re-initiates fever, myalgia and pruriginous rash on inner thighs  hospitalized • usual medication was resumed

  9. physicalexamination • Oximetry (FiO2 21%): 98% • No signs of respiratory distress • Pulmonary auscultation: bilateral symmetric sounds with crackles in both lung bases • Maculopapular skin lesions on the trunk and limbs, most evident in the inner thighs and abdominal wall with dermographism • No other changes

  10. Diagnostic test results • Blood analysis: • Normal hemoglobin • Mild leukocytosis[12.33x109/L (N 4-11x109/L)], with eosinophilia [18.2% – 2.24x109/L (N 0.6-4.6%)] • CRP 132.9 mg/L

  11. Diagnostic test results • Chest X-ray: heterogeneous left perihilar opacity and a micronodular pattern at the right lung base

  12. Diagnostic test results • High-resolutionChest CT:peribronchovascularopacity most evident in the periphery of the LLL, associated with air bronchogram and slight thickening of the interlobular septa; bilateral discrete ground-glass micronodular pattern

  13. Diagnostic test results • High-resolutionChest CT:peribronchovascularopacity most evident in the periphery of the LLL, associated with air bronchogram and slight thickening of the interlobular septa; bilateral discrete ground-glass micronodular pattern

  14. Diagnostic test results • Bronchoscopy: without morphological or topographical • features • BAL: lymphocyte 6.4%, macrophages 83.8%, neutrophils 0.4%, eosinophils 9%, mast cells 0.4%; cytology negative for malignant cells, no microorganisms were found

  15. Diagnostic test results • Transthoracic needle aspiration biopsy

  16. Two adequate fragments of transthoracic biopsy

  17. Expansion of alveolar septa by edema and a mixed inflammatory infiltrate Organizing pneumonia lesions and pneumocyte hyperplasia

  18. Prominent eosinophilic interstitial infiltrate, with some clustering; few within alvelar spaces

  19. Diagnosis: Morphologic features of eosinophilic pneumonia(integrate in the clinical/radiologic context)

  20. Diagnostic test results • Complementary blood analysis • IgE 737 kU/L (N < 114) • Sedimentation velocity 48mm/1st h (N < 20) • Remaining immunological, autoimmune and serological study without abnormalities • Immunophenotyping of peripheral blood: T cells with abnormal expression of CD3; polyclonal B population • Bone marrow biopsy: reactive changes • Skin biopsy: chronic nonspecific epidermotropic dermatitis • Cultural tests (hemocultures, urine culture, stool examination, BAL, pulmonary biopsy): negative

  21. SUMMARY • FEVER • SKIN RASH • EOSINOPHYLIA • PULMONARY OPACTITIES Temporal relationwithfenofibrateintrodution

  22. Final diagnosis • PROBABLE DRESS SYNDROME • (associated with fenofibrate) • EOSINOPHILIC PNEUMONIA (in the context of fenofibrate?)

  23. evolution • Fenofibrate was stopped • Subsequently resolution of symptoms Marked regression of parenchymal consolidation areas, persisting mild residual features.

  24. DISCONTINUATION OF FIBRATE

  25. evolution • February 2014 • Clinical, radiological and analytical improvement

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