Chronic Eosinophilic Pneumonia and Allergic...
Transcript of Chronic Eosinophilic Pneumonia and Allergic...
Chronic Chronic EosinophilicEosinophilic
Pneumonia and Pneumonia and Allergic Allergic BronchopulmonaryBronchopulmonary
AspergillosisAspergillosis: Two : Two eosinophiliceosinophilic
lung lung diseases in one patient.diseases in one patient.
Andrés F. MirandaUniversidad de Antioquia, Faculty of Medicine
Gillian Lieberman, MD.
Andres MirandaGillian Lieberman, MDAugust, 2011
Andres MirandaGillian Lieberman, MDAugust, 2011
AgendaAgenda• Index case presentation.
• Eosinophilic Lung Diseases.o Chronic eosinophilic pneumonia.
• Presentation.• Diagnostic studies.• Imaging.• Differential diagnosis.
o Churg-Strauss Syndrome.o Bronchiolitis obliterans organizing pneumonia.o Simple pulmonary eosinophilia (Loeffler syndrome).
• Patient additional work-up.
• Allergic bronchopulmonary aspergillosis.
• Case analysis.
• Conclusions.
• References.
• Acknowledgements.2
Andres MirandaGillian Lieberman, MDAugust, 2011
Index Index patientpatient presentationpresentation..
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Andres MirandaGillian Lieberman, MDAugust, 2011
OurOur
patientpatient: : HistoryHistory
ofof
presentpresent
illnessillness• 40 year old female reports for consultation with
cough, weight loss, abnormal CXR, and sputum growing AFB.
• She c/o worsening chronic cough; clear sputum, Some DOE. She has sustained an 15 pounds weight loss over the past year. Denies hemoptysis.
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Andres MirandaGillian Lieberman, MDAugust, 2011
OurOur
patientpatient: : ReviewReview
ofof
systemssystems• Prominent malaise; fatigue; more than 30 pounds weight loss
over past several years.
• Denies SOB at rest; no stridor, intermittent wheeze.
• Denies fevers, chills, or sweats.
• Denies chest pain, chest pressure, or palpitations.
• No abdominal pain; no NVD
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Andres MirandaGillian Lieberman, MDAugust, 2011
OurOur
patientpatient: : PastPast
medical medical historyhistory• Abnormal CXR in India 2005: biapical scarring.
• Not clear if previous history of asthma.
• BCG vaccination.
• No medications.
• No Known drug allergies.
• No recent epidemiologic exposures.6
Andres MirandaGillian Lieberman, MDAugust, 2011
OurOur
patientpatient: : PhysicalPhysical
examinationexamination• General: Cachectic, no acute distress.
• Vital signs: HR: 120, Sat: 91-93, T: 98.8.
• Lungs: diffuse rhonchi; diffuse coarse rales.
• Cardiac, abdominal, neurologic, extremities and skin were within normal limits.
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Andres MirandaGillian Lieberman, MDAugust, 2011
OurOur patientpatient: : InitialInitial
WorkWork‐‐upup
• WBC was 9.1 with 57segs, 21 lymphs, and 13.8 eos.• ESR: 30.• AFB culture negative one month before
consultation.• Recently Negative PPD• Of course !!!! CXR.• HIV, Hept B, Hept C and liver function tests were
within normal.
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Andres MirandaGillian Lieberman, MDAugust, 2011
OurOur
patientpatient: Pleural : Pleural thickeningthickening, , consoloditationconsoloditation
andand reticulonodularreticulonodular
patternpattern
onon
InitialInitial
PA CXRPA CXR
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• Bilateral zones
of pleural
thickening and
consolidation,
predominant in
the periphery.
PACS, BIDMC
Furthermore a
diffuse
reticulonodular
pattern is present.
Andres MirandaGillian Lieberman, MDAugust, 2011
OurOur patientpatient: : parenchimalparenchimal
densitiesdensities InitialInitial
CXR lateralCXR lateral
• Diffuse parenchimal densities more accentuated in upper lobes.
10PACS, BIDMC
Andres MirandaGillian Lieberman, MDAugust, 2011
• What is the differential diagnosis of a patient with history of general and chronic respiratory symptoms, marked peripheral eosininophilia and diffuse findings on CXR ?
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Andres MirandaGillian Lieberman, MDAugust, 2011
EosinophilicEosinophilic Lung Lung DiseasesDiseases
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Andres MirandaGillian Lieberman, MDAugust, 2011
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Andres MirandaGillian Lieberman, MDAugust, 2011
ChronicChronic EosinophilicEosinophilic
PneumoniaPneumonia (CEP)(CEP)
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Andres MirandaGillian Lieberman, MDAugust, 2011
CEP: CEP: PresentationPresentation• Insidious onset and progressive.• General manifestations:
o Asthenia, weight loss, nocturnal sweat or fever could be frequent.
• Pulmonary signs:o Dyspnea, cough, wheezing could be present.
• Physical examination: Hypoxemia, tachycardia, rales and wheezes.
• Twice more frequent in women.• 1/3 previous history of asthma.
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Andres MirandaGillian Lieberman, MDAugust, 2011
CEP: CEP: DiagnosticDiagnostic studiesstudies
Laboratory findings• Market peripheral eosinophilia.• ESR and CRP usually elevated.• IgE leves elevated in 50% of the cases.• Bronchoalveolar lavage (BAL): Allways high
percentage of eosinophils.• Restrictive pattern or obstructive on lung function
tests could be found.
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Andres MirandaGillian Lieberman, MDAugust, 2011
CompanionCompanion
patientpatient
#1: #1: UpperUpper
lobeslobes
consolidationconsolidation
onon
CXRCXR
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Areas of air space
consolidation.
Which are
predominant in the
upper lobes.
Yeon
J, et al. Eosinophilic
Lung Disease: A clinical, radiolic
and
pathologic overview, RadioGraphics. 2007
Companion patient #2: migratory infiltrates on CXRCompanion patient #2: migratory infiltrates on CXR
Migratory pulmonary infiltrates, zones of consolidation distributed peripherally.
18Mendes L, et al. Pulmonary eosinophilia, The Jornal Brasileiro de
Pneumologia. 2009
Andres MirandaGillian Lieberman, MDAugust, 2011
Andres MirandaGillian Lieberman, MDAugust, 2011
CompanionCompanion
patientpatient
#3: #3: ““PhotographicPhotographic negativenegative
ofof
pulmonarypulmonary
edemaedema””
CXRCXR
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The peripheral distribution of abnormalities results in the typical finding of “Photographic negative of pulmonary
edema.”
UpToDate, 2011
Andres MirandaGillian Lieberman, MDAugust, 2011
Companion patient #4: Companion patient #4: subpleuralsubpleural
consolidation and consolidation and pleural effusion on Chest CTpleural effusion on Chest CT
Other common findings
are subpleural
areas of
consolidation in both
lungs.
Right pleural effusion is
also seen, but is
observed in less than
10%.
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Yookyung
Kim, et al. The spectrum of eosinophilic
lung disease:
radiologic findings. Journal of computer assisted tomography. 1997
C – axial chest CT. Lung window
Andres MirandaGillian Lieberman, MDAugust, 2011
Companion patient #5: ground glass opacities on Companion patient #5: ground glass opacities on Chest CTChest CT
Bilateral asymmetrical areas of Ground glass opacities in peripheral distribution.
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Adam. Grainger & Allisonʹs Diagnostic Radiology A
Textbook of Medical Imaging. 5th
edition
C – axial chest CT. Lung window
Andres MirandaGillian Lieberman, MDAugust, 2011
Differential diagnosisDifferential diagnosis• Focus on clinical and radiologic findings, and
additional work up, the differential diagnosis includes:
o Churg-Strauss Syndrome (CSS).o Bronchiolitis obliterans organizing pneumonia (BOOP).o Simple pulmonary eosinophilia (SPE)
All of these diseases have eosinophilia as a remarkable finding.
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Andres MirandaGillian Lieberman, MDAugust, 2011
ChurgChurg‐‐Strauss syndromeStrauss syndrome (CSS)(CSS)
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Andres MirandaGillian Lieberman, MDAugust, 2011
CCS: PresentationCCS: PresentationChurg-Strauss Syndrome:• Clinically:
o Extrapulmonary involvement: Neurological, paranasal sinus, cardiac and skin.
o Previous history of asthma.
• Perinuclear - Anti-neutrophil cytoplasmic antibodies (P-ANCA) is found positive in 48 -73% of patients.
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Andres MirandaGillian Lieberman, MDAugust, 2011
CSS: Bilateral opacities and CSS: Bilateral opacities and enlarged heart size on CXRenlarged heart size on CXR
• Bilateral opacities in both lower lobes and enlarged heart size which was proved to be pericardial effusion on CT.
25Yookyung
Kim, et al. The spectrum of eosinophilic
lung disease: radiologic
findings. Journal of computer assisted tomography. 1997
Andres MirandaGillian Lieberman, MDAugust, 2011
CSS: consolidation, ground glass opacities, pleural CSS: consolidation, ground glass opacities, pleural and pericardial effusions on Chest CTand pericardial effusions on Chest CT
• Characteristics of eosinophilic lung involvement are Lung consolidation in the right lung and Ground glass opacities in the left side.
• Bilateral Pleural effusions and pericardial effusion. Subsequent to cardiomyopathy.
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Mason: Murray and Nadelʹs Textbook of Respiratory
Medicine,
5th ed.
C – axial chest CT. Lung window
Andres MirandaGillian Lieberman, MDAugust, 2011
CSS: Multiple CSS: Multiple centrilobularcentrilobular
nodules, bronchial wall nodules, bronchial wall thickening and ground glass opacities on Chest CTthickening and ground glass opacities on Chest CT
• Other common findings are multiple centrilobular nodules, bronchial wall thickening. Also some areas of diffuse ground glass opacities are present.
27Yeon
J, et al. Eosinophilic
Lung Disease: A clinical, radiolic
and
pathologic overview, RadioGraphics. 2007
C – axial chest CT. Lung window
Andres MirandaGillian Lieberman, MDAugust, 2011
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BronchiolitisBronchiolitis obliteransobliterans
organizing pneumoniaorganizing pneumonia (BOOP)(BOOP)
Andres MirandaGillian Lieberman, MDAugust, 2011
BOOP: Presentation and laboratoryBOOP: Presentation and laboratory• Histological diagnosis of organizing pneumonia of
unknown etiology.
• Clinical:o Short history of cough, dyspnea, fever, malaise and weight loss.
• Excellent response to corticosteroid treatment, but relapses are common.
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Andres MirandaGillian Lieberman, MDAugust, 2011
BOOP: Relapsing consolidationsBOOP: Relapsing consolidations
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Adam. Grainger & Allisonʹs Diagnostic Radiology A Textbook of Medical Imaging. 5th
edition
Multifocal consolidation in upper and mid zones, the relapse
is present
after stopping the treatment, a suggestive characteristic of this condition.
Andres MirandaGillian Lieberman, MDAugust, 2011
BOOP: consolidation and ground glass opacities BOOP: consolidation and ground glass opacities on Chest CTon Chest CT
• areas of consolidation in both upper lobes, with associated ground-glass opacification.
31Adam. Grainger & Allisonʹs Diagnostic Radiology A Textbook of Medical
Imaging. 5th
edition
C – axial chest CT. Lung window
Andres MirandaGillian Lieberman, MDAugust, 2011
BOOP: consolidation and ground glass opacities BOOP: consolidation and ground glass opacities affecting both lungs.affecting both lungs.
• These consolidations and ground- glass opacification. Could be present in all lobes.
32Adam. Grainger & Allisonʹs Diagnostic Radiology A Textbook of Medical
Imaging. 5th edition
C – axial chest CT. Lung window
Andres MirandaGillian Lieberman, MDAugust, 2011
Simple Simple pulmonarypulmonary eosinophiliaeosinophilia
((LoefflerLoeffler SyndromeSyndrome))
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Andres MirandaGillian Lieberman, MDAugust, 2011
Simple Simple pulmonarypulmonary
eosinophiliaeosinophilia: : PresentationPresentation
• It is due to the passage of some parasites, especially nematodes, through the lung.
• Could be asymptomatic or just general symptoms.
• The most common causes are: Ascaris lumbricoides, Strongiloides Stercoralis and Toxocara canis.
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Andres MirandaGillian Lieberman, MDAugust, 2011
Simple Simple pulmonarypulmonary
eosinophiliaeosinophilia: : MigratoryMigratory
opacitiesopacities..
• Migratory opacities with peripheral distribution.
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Sharma Girish. Loeffler
syndrome. Medscape
reference
Andres MirandaGillian Lieberman, MDAugust, 2011
Simple Simple pulmonarypulmonary
eosinophiliaeosinophilia: : GroundGround
glassglass opacitiesopacities
onon
chestchest
CTCT
• Mixed bilateral areas of consolidation and ground glass opacities. Usually these changes resolve spontaneously within one month.
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C – axial chest CT. Lung window
Yeon
J, et al. Eosinophilic
Lung Disease: A clinical, radiolic
and
pathologic overview, RadioGraphics. 2007
Andres MirandaGillian Lieberman, MDAugust, 2011
SPE: SPE: OtherOther findingsfindings
onon
CTCT
• This lesion could be a common finding in patient with Loeffler syndrome, and can be concerning about malignancy, however in this case it dissapear completely at follow-up.
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Pulmonary
nodule
Yeon
J, et al. Eosinophilic
Lung Disease: A clinical, radiolic
and
pathologic overview, RadioGraphics. 2007
C – axial chest CT. Lung window
Andres MirandaGillian Lieberman, MDAugust, 2011
Going back to our patient:Going back to our patient: Additional workAdditional work‐‐upup
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Andres MirandaGillian Lieberman, MDAugust, 2011
OurOur patientpatient: Hospital : Hospital
admissionadmissionOur patient was admitted to the hospital for In-patient work-up,
where she underwent:• Bronchoalveolar lavage (BAL): Red blood cells: 0 Polys: 11,
Lymphs: 6, Monos: 0, Eos: 44, Macro: 39.
• ABG: Hypoxemia.
• Bronchoscopy: Negative for anatomic abnormality.
• Parasites serology: Negative.
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Andres MirandaGillian Lieberman, MDAugust, 2011
OurOur patientpatient: : DiagnosticDiagnostic
teststests• Lung biopsy: fibrosis and scarring, increased
number of eosinophiles. Involves bronchial walls, changes suggestive of pulmonary hypertension.
• P-ANCA: Negatives.
• Control CBC showed WBC: 10,000 with 19% eosinophils(2000). ESR: 71
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Andres MirandaGillian Lieberman, MDAugust, 2011
OurOur patientpatient: more : more
diagnosticdiagnostic teststests
• Total IgE: 4916.
• Allergens skin testing: Panelevation of enviromental allergens, including Aspergillus.
• Spirometry: Severe restrictive pattern.
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Our patient: fibrosis and ground glass Our patient: fibrosis and ground glass opacities on Chest CTopacities on Chest CT
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Andres MirandaGillian Lieberman, MDAugust, 2011
Areas of fibrosis in
both upper lobes
with subpleural
distributions.
Bilateral Ground
glass opacities
PACS, BIDMC
C – axial chest CT. Lung window
Our patient: fibrosis and loss of Our patient: fibrosis and loss of volume on chest CTvolume on chest CT
• Bilateral peripheral fibrosis, along with signs of right upper lobe loss of volume.
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Andres MirandaGillian Lieberman, MDAugust, 2011
PACS, BIDMC
C –
coronal chest CT. Lung window
Our patient: Our patient: bronchiectasisbronchiectasis, mucus , mucus impactationimpactation and and centrilobularcentrilobular
nodules on chest CTnodules on chest CT
• Bilateral bronchiectasis radiating from perihilar areas.• Zone of mucus impactation, within bronchiectasis.• Centrilobular nodules.
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Andres MirandaGillian Lieberman, MDAugust, 2011
PACS, BIDMC
C – axial chest CT. Lung window
Andres MirandaGillian Lieberman, MDAugust, 2011
Allergic Allergic BronchopulmonaryBronchopulmonary
AspergillosisAspergillosisA new diagnosis to take into account in our patient.
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Andres MirandaGillian Lieberman, MDAugust, 2011
PresentationPresentation• Patient with previous history of asthma.
• There are essential findings for the diagnosis:o Skin test reactivity to Aspergillus sp.
o Total IgE level more than 1000 U/L.
o IgE or IgG against Aspergillus sp. In the blood.
o Peripheral blood eosinophilia.
• Symptoms are general and there are no specific clinical findings other than these of asthma.
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Andres MirandaGillian Lieberman, MDAugust, 2011
CompanionCompanion
patientpatient
#6: #6: opacitiesopacities
andand
dilateddilated
bronchibronchi onon
CXRCXR
• Opacities in both upper lung zones and round opacity in left
lower lung zone. Also dilated bronchi in right side are
present.
47Yookyung
Kim, et al. The spectrum of eosinophilic
lung disease: radiologic
findings. Journal of computer assisted tomography. 1997
Andres MirandaGillian Lieberman, MDAugust, 2011
CompanionCompanion
patientpatient
#7: Mucus #7: Mucus pluggingplugging
andand bronchiectasisbronchiectasis
onon
ChestChest
CTCT
48Goldman: Goldmanʹs Cecil Medicine,
24th ed.
Tubular
and cystic
bronchiectasis
Bilateral zones of
mucous plugging.
C – axial chest CT. Lung window
Andres MirandaGillian Lieberman, MDAugust, 2011
These findings are almost pathognomonic of Allergic
Bronchopulmonary Aspergillosis in patients with previous history
of asthma, elevated eosinophil count and high serum IgE
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Andres MirandaGillian Lieberman, MDAugust, 2011
Patient analysisPatient analysis
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Andres MirandaGillian Lieberman, MDAugust, 2011
OutcomeOutcomeThe diagnosis of Chronic eosinphilic pneumonia and
Allergic Bronchopulmonary Aspergillosis was made based on the following:
• Clinical findings: o Long history of respiratory and general symptoms.o Non clear PMH positive for asthma.
• Laboratory:o Peripheral eosinophilia greater than 1.000 /uL.o Persistent elevated ESR.o IgE level higher than 1.000 U/L.o Severe restrictive pattern on lung function test.o BAL and byopsia: Market eosinophilia and inflammatory changes.o Exclusion of other possible causes: Infection, vasculitis.
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Andres MirandaGillian Lieberman, MDAugust, 2011
Summary of imaging Summary of imaging findingsfindings
• Chest X-ray: o Parenchimal densities more accentuated in upper lobes.o Generalized linear opacities.o Peripheral pleural thckening.
• Chest CT:o Areas of peropheral fibrosis and bilateral ground glass opacities
predominant in upper lobes.o Bilateral bronchiectasis and mucous impactation.o Centrilobular nodules.
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Andres MirandaGillian Lieberman, MDAugust, 2011
After the diagnosis was made, the therapy was optimized and patient has been doing well with symptoms last years; however
his findings on pulmonary imaging have not improved much, because the patient is in the fibrotic phase of the disease,
which is irreversible.
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ConclusionsConclusions
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Andres MirandaGillian Lieberman, MDAugust, 2011
Andres MirandaGillian Lieberman, MDAugust, 2011
ConclusionsConclusions• There are a big number of conditions that can cause
peripheral eosinophilia along with pulmonary symptoms, in these cases extended work-up will be necessary in order to make a right diagnosis and provide correct treatment.
• Different modalities of imaging, such as chest X-ray and CT, play an important role in the diagnosis of these diseases.
• The approach bases on radiologic and clinical findings usually is enough and invasive procedures, as byopsies could be avoided.
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ReferencesReferences• Jeong Yeon Joo , Kun-il Kim, Im Jeong Seo, Chang Hun Lee, Ki Nam Lee, Ki Nam Kim, et al. Eosinophilic
Lung Diseases: A clinical Radiologic, and Pathologic overview. Radiographics. 2007; 27: 617-639.• Mendes Luiz, Luiz Fernando Ferreira. Pulmonary eosinophilia. The Jornal Brasileiro de Pneumologia. 2009;
35(6): 561-573• Cottin Vincent, Jean-Francois Cordier. Eosinophilic pneumonias. Allergy. 2005; 60: 841-857.• Franquet Tomas, Nestor L Muller, Ana Gimenez, Pedro Guembe, Jesus de la Torre, S. Bague.
Radiographics. 2001; 21: 825-837.• Marchand Eric, Jean-Francois Cordier. Idiopathic chronic eosinophilic pneumonia. Orphanet journal of
Rare diseases. 2006, 1:11.• Yookyung Kim, Kyung Soo Lee, Dong-Chull Choi, Steven L Primack, Jung-Gi Im. The spectrum of
eosinophilic lung disease: radiologic findings. Journal of computer assisted tomography. 1997; 21(6): 920- 930.
• Klion Amy D, Peter F Weller. Causes of pulmonary eosinophilia. 2011. UpToDate online.• King Talmadge Jr, Kevin K Brown. Treatment of idiopathic acute eosinophilic. 2011. UpToDate onlie.• Goldman. Goldman’s Cecil Medicine. 24th edition. New York: Elsevier Saunders. 2011. URL:
http://www.mdconsult.com.libaccess.lib.mcmaster.ca/books/. Accesed 08/22/2011• Mason: Murray and Nadel's. Textbook of Respiratory Medicine. 5th edition. New York: Elsevier Saunders.
2010. URL: http://www.mdconsult.com.libaccess.lib.mcmaster.ca/books/. Accesed 08/22/2011.• Adam. Grainger & Allison's Diagnostic Radiology A Textbook of Medical Imaging. 5th edition. Elsevier
Churchill livingstone. 2008. URL: http://www.mdconsult.com.libaccess.lib.mcmaster.ca/books. Accesed 08/22/2011.
• Sharma Girish. Loeffler syndrome. Medscape reference. URL: http://emedicine.medscape.com/article/1002606-overview. Accesed 08/22/2011.
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Andres MirandaGillian Lieberman, MDAugust, 2011
AcknowledgementsAcknowledgements
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Andres MirandaGillian Lieberman, MDAugust, 2011
I would like to thankI would like to thank……• Dr. Alexander Bankier.
• Dr. Ammar Sarwar.
• Dr. Javier Perez.
• Dr. Gillian Lieberman.
• Emiliy Hanson.
• Classmates of Harvard Medical School.
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Andres MirandaGillian Lieberman, MDAugust, 2011