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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.

Summary

Abstract

We describe the case of a 45-year-old female who developed pulmonary infiltrates and mild eosinophilia following an overdose of ibuprofen. We believe this was a case of pulmonary infiltrates with eosinophilia (PIE) syndrome and discuss the relevant literature. Although rare, PIE syndrome should be considered in those taking nonsteroidal anti-inflammatories who develop unexplained pulmonary infiltrates.

Aim

Method

Results

Conclusion

Author Information

Nicole Vogts, Trainee Intern; Simon Young, Physician and Endocrinologist; Department of Medicine, North Shore Hospital, Waitemata District Health Board, Takapuna, Auckland

Acknowledgements

Correspondence

Dr Simon Young, Department of Medicine, North Shore Hospital, Private Bag 93-503, Takapuna, Auckland 0740, New Zealand.

Correspondence Email

simon.young@waitematadhb.govt.nz

Competing Interests

Goodwin S, Glenny R. Nonsteroidal anti-inflammatory drug-associated pulmonary infiltrates with eosinophilia. Archives of Internal Medicine. 1992 Jul;152(7):1521-4.Ueda K, Sakano H, Tanaka T, et al. Diclofenac (Voltaren)-induced pneumonitis after chest operation. . Annals of Thoracic Surgery. 2002 Dec;74(6):2176-7.Khalil H, Molinary E, Stoller J. Diclofenac (Voltaren)-induced eosinophilic pneumonitis. Archives of Internal Medicine. 1993 Jul 26;153(14):1649-52.Janz D, O'Neal H, Ely E. Acute eosinophilic pneumonia: A case report and review of the literature. Critical Care Medicine. 2009 Apr;37(4):1470-4.Rich M, Thomas R. A case of eosinophilic pneumonia and vasculitis induced by diflunisal. Chest. 1997 Jun;111(6):1767-9.Perng D, Su H, Tseng C, Lee Y. Pulmonary infiltrates with eosinophilia induced by nimesulide in an asthmatic patient. . Respiration. 2005 Nov-Dec;72(6):651-3.Burton G. Rash and pulmonary eosinophilia associated with fenbufen. BMJ. 1990 Jan 13;300(6717):82-3.Karakatsani A, Chroneou A, Koulouris N, et al. Meloxicam-induced pulmonary infiltrates with eosinophilia: a case report. Rheumatology. 2003 Sept;42(9):1112-3.

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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.

Summary

Abstract

We describe the case of a 45-year-old female who developed pulmonary infiltrates and mild eosinophilia following an overdose of ibuprofen. We believe this was a case of pulmonary infiltrates with eosinophilia (PIE) syndrome and discuss the relevant literature. Although rare, PIE syndrome should be considered in those taking nonsteroidal anti-inflammatories who develop unexplained pulmonary infiltrates.

Aim

Method

Results

Conclusion

Author Information

Nicole Vogts, Trainee Intern; Simon Young, Physician and Endocrinologist; Department of Medicine, North Shore Hospital, Waitemata District Health Board, Takapuna, Auckland

Acknowledgements

Correspondence

Dr Simon Young, Department of Medicine, North Shore Hospital, Private Bag 93-503, Takapuna, Auckland 0740, New Zealand.

Correspondence Email

simon.young@waitematadhb.govt.nz

Competing Interests

Goodwin S, Glenny R. Nonsteroidal anti-inflammatory drug-associated pulmonary infiltrates with eosinophilia. Archives of Internal Medicine. 1992 Jul;152(7):1521-4.Ueda K, Sakano H, Tanaka T, et al. Diclofenac (Voltaren)-induced pneumonitis after chest operation. . Annals of Thoracic Surgery. 2002 Dec;74(6):2176-7.Khalil H, Molinary E, Stoller J. Diclofenac (Voltaren)-induced eosinophilic pneumonitis. Archives of Internal Medicine. 1993 Jul 26;153(14):1649-52.Janz D, O'Neal H, Ely E. Acute eosinophilic pneumonia: A case report and review of the literature. Critical Care Medicine. 2009 Apr;37(4):1470-4.Rich M, Thomas R. A case of eosinophilic pneumonia and vasculitis induced by diflunisal. Chest. 1997 Jun;111(6):1767-9.Perng D, Su H, Tseng C, Lee Y. Pulmonary infiltrates with eosinophilia induced by nimesulide in an asthmatic patient. . Respiration. 2005 Nov-Dec;72(6):651-3.Burton G. Rash and pulmonary eosinophilia associated with fenbufen. BMJ. 1990 Jan 13;300(6717):82-3.Karakatsani A, Chroneou A, Koulouris N, et al. Meloxicam-induced pulmonary infiltrates with eosinophilia: a case report. Rheumatology. 2003 Sept;42(9):1112-3.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

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.

Summary

Abstract

We describe the case of a 45-year-old female who developed pulmonary infiltrates and mild eosinophilia following an overdose of ibuprofen. We believe this was a case of pulmonary infiltrates with eosinophilia (PIE) syndrome and discuss the relevant literature. Although rare, PIE syndrome should be considered in those taking nonsteroidal anti-inflammatories who develop unexplained pulmonary infiltrates.

Aim

Method

Results

Conclusion

Author Information

Nicole Vogts, Trainee Intern; Simon Young, Physician and Endocrinologist; Department of Medicine, North Shore Hospital, Waitemata District Health Board, Takapuna, Auckland

Acknowledgements

Correspondence

Dr Simon Young, Department of Medicine, North Shore Hospital, Private Bag 93-503, Takapuna, Auckland 0740, New Zealand.

Correspondence Email

simon.young@waitematadhb.govt.nz

Competing Interests

Goodwin S, Glenny R. Nonsteroidal anti-inflammatory drug-associated pulmonary infiltrates with eosinophilia. Archives of Internal Medicine. 1992 Jul;152(7):1521-4.Ueda K, Sakano H, Tanaka T, et al. Diclofenac (Voltaren)-induced pneumonitis after chest operation. . Annals of Thoracic Surgery. 2002 Dec;74(6):2176-7.Khalil H, Molinary E, Stoller J. Diclofenac (Voltaren)-induced eosinophilic pneumonitis. Archives of Internal Medicine. 1993 Jul 26;153(14):1649-52.Janz D, O'Neal H, Ely E. Acute eosinophilic pneumonia: A case report and review of the literature. Critical Care Medicine. 2009 Apr;37(4):1470-4.Rich M, Thomas R. A case of eosinophilic pneumonia and vasculitis induced by diflunisal. Chest. 1997 Jun;111(6):1767-9.Perng D, Su H, Tseng C, Lee Y. Pulmonary infiltrates with eosinophilia induced by nimesulide in an asthmatic patient. . Respiration. 2005 Nov-Dec;72(6):651-3.Burton G. Rash and pulmonary eosinophilia associated with fenbufen. BMJ. 1990 Jan 13;300(6717):82-3.Karakatsani A, Chroneou A, Koulouris N, et al. Meloxicam-induced pulmonary infiltrates with eosinophilia: a case report. Rheumatology. 2003 Sept;42(9):1112-3.

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