A rare complication of non-steroidal anti-inflammatory drug (NSAID) use is pulmonary infiltrates with eosinophilia (PIE) syndrome.We report a case of suspected PIE syndrome in the context of NSAID overdose.Case reportA 45-year-old female with background of opiate addiction presented with a 2-day history of drowsiness following a drug overdose of 72 Neurofen Plus tablets (containing codeine and ibuprofen). Blood tests revealed acute renal failure, markedly deranged electrolytes and features of renal tubular acidosis.A chest X-ray (CXR) showed bilateral patchy peripheral infiltrates, affecting the right midzone and left upper lobe. A computed tomography pulmonary angiogram (CTPA) excluded pulmonary embolism (PE), but showed multiple areas of ground-glass attenuation affecting predominantly the peripheral upper lobe, along with trace pleural effusions.The patient had no symptoms of infection and remained afebrile but slightly tachypnoeic. Her C-reactive protein was 53 mg/L and white blood cell count was 17.7×109/L. The eosinophil count was initially normal but rose to 0.6×109/L (N<0.5) after 3 days. She was treated with intravenous fluids and oral antibiotics for possible aspiration.Her renal function and acidosis improved over 5 days. A repeat CXR showed reduced but persistent infiltrates that had resolved at follow-up after 4 weeks.DiscussionPulmonary infiltrates with eosinophilia (PIE) syndrome is characterised by diffuse eosinophilia: peripherally, on bronchial alveolar lavage, and on lung biopsy.1 Symptoms, where present, include fever, cough, dyspnoea, malaise and rash.2 Typical radiological features are pleural effusions, bilateral upper lobe and peripheral infiltrates and areas of patchy consolidation.3PIE syndrome has been described in the literature in association with around 50 classes of medication.1,4,5 NSAIDs have been reported as causative agents and both selective COX2 inhibitors and non-selective NSAIDs have been implicated.1,6-8The syndrome typically presents 1 to 2 weeks after drug exposure begins, and occurrence is believed to be unrelated to dose or duration of use.5 A hypersensitivity reaction is the proposed causative mechanism due to the widespread eosinophilia, rash, and rapid response on drug rechallenge.Symptoms and signs of NSAID-induced PIE syndrome typically resolve completely within 2 weeks of discontinuation of the implicated medication, although radiological findings may be slower to improve.3,8Some case studies have suggested an apparent response to systemic or inhaled corticosteroids.5,6 Permanent fibrosis is a proposed outcome of PIE syndrome but is rare.1The actual incidence of PIE syndrome may be underestimated due to poor awareness of this diagnosis and the widespread use of these agents.A drug reaction should be considered in patients taking NSAIDs who present with pulmonary infiltrates that are otherwise unexplained.

A rare complication of non-steroidal anti-inflammatory drug (NSAID) use is pulmonary infiltrates with eosinophilia (PIE) syndrome.We report a case of suspected PIE syndrome in the context of NSAID overdose.Case reportA 45-year-old female with background of opiate addiction presented with a 2-day history of drowsiness following a drug overdose of 72 Neurofen Plus tablets (containing codeine and ibuprofen). Blood tests revealed acute renal failure, markedly deranged electrolytes and features of renal tubular acidosis.A chest X-ray (CXR) showed bilateral patchy peripheral infiltrates, affecting the right midzone and left upper lobe. A computed tomography pulmonary angiogram (CTPA) excluded pulmonary embolism (PE), but showed multiple areas of ground-glass attenuation affecting predominantly the peripheral upper lobe, along with trace pleural effusions.The patient had no symptoms of infection and remained afebrile but slightly tachypnoeic. Her C-reactive protein was 53 mg/L and white blood cell count was 17.7×109/L. The eosinophil count was initially normal but rose to 0.6×109/L (N<0.5) after 3 days. She was treated with intravenous fluids and oral antibiotics for possible aspiration.Her renal function and acidosis improved over 5 days. A repeat CXR showed reduced but persistent infiltrates that had resolved at follow-up after 4 weeks.DiscussionPulmonary infiltrates with eosinophilia (PIE) syndrome is characterised by diffuse eosinophilia: peripherally, on bronchial alveolar lavage, and on lung biopsy.1 Symptoms, where present, include fever, cough, dyspnoea, malaise and rash.2 Typical radiological features are pleural effusions, bilateral upper lobe and peripheral infiltrates and areas of patchy consolidation.3PIE syndrome has been described in the literature in association with around 50 classes of medication.1,4,5 NSAIDs have been reported as causative agents and both selective COX2 inhibitors and non-selective NSAIDs have been implicated.1,6-8The syndrome typically presents 1 to 2 weeks after drug exposure begins, and occurrence is believed to be unrelated to dose or duration of use.5 A hypersensitivity reaction is the proposed causative mechanism due to the widespread eosinophilia, rash, and rapid response on drug rechallenge.Symptoms and signs of NSAID-induced PIE syndrome typically resolve completely within 2 weeks of discontinuation of the implicated medication, although radiological findings may be slower to improve.3,8Some case studies have suggested an apparent response to systemic or inhaled corticosteroids.5,6 Permanent fibrosis is a proposed outcome of PIE syndrome but is rare.1The actual incidence of PIE syndrome may be underestimated due to poor awareness of this diagnosis and the widespread use of these agents.A drug reaction should be considered in patients taking NSAIDs who present with pulmonary infiltrates that are otherwise unexplained.