Letter to the Editor
Sulfasalazine-induced Hypereosinophilic Obliterative Bronchiolitis
Bronquiolitis obliterante hipereosinofílica inducida por sulfasalazina
Stamatis Katsenos
, Elvira-Markela Antonogiannaki, Konstantinos Psathakis
Corresponding author
Department of Pneumonology, Army General Hospital of Athens, Atenas, Greece
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"cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Sulfasalazine-induced Hypereosinophilic Obliterative Bronchiolitis" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor</span>," "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "108" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Stamatis Katsenos, Elvira-Markela Antonogiannaki, Konstantinos Psathakis" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Stamatis" "apellidos" => "Katsenos" "email" => array:1 [ 0 => "skatsenos@yahoo.gr" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Elvira-Markela" "apellidos" => "Antonogiannaki" ] 2 => array:2 [ "nombre" => "Konstantinos" "apellidos" => "Psathakis" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Pneumonology, Army General Hospital of Athens, Atenas, Greece" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bronquiolitis obliterante hipereosinofílica inducida por sulfasalazina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1153 "Ancho" => 1626 "Tamanyo" => 158673 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">High resolution computed tomography of the chest in expiration, showing bilateral mosaic attenuation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">No cases of drug-induced hypereosinophilic obliterative bronchiolitis (HOB) have been previously reported in the literature, and, to our knowledge, this is the first documented case of sulfasalazine-induced BOH in a patient with ulcerative colitis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 61-year-old man, non-smoker, with a history of ulcerative colitis, who had been receiving sulfasalazine treatment for more than 3 years, consulted in January 2012 with a 6-month history of dry cough and progressive dyspnea. Spirometry showed severe airflow obstruction (FEV<span class="elsevierStyleInf">1</span>=890<span class="elsevierStyleHsp" style=""></span>ml [30%]; FVC=1670<span class="elsevierStyleHsp" style=""></span>ml [44%]; FEV<span class="elsevierStyleInf">1</span>/FVC=[53%]). High-resolution computed tomography (HRCT) revealed bilateral pulmonary opacities, predominantly in the upper lung regions. Clinical laboratory tests showed eosinophilia in blood and in bronchoalveolar lavage fluid (7.6<span class="elsevierStyleHsp" style=""></span>g/l and 80%, respectively). The patient was diagnosed with eosinophilic pneumonia; sulfasalazine was switched to 40<span class="elsevierStyleHsp" style=""></span>mg prednisone once a day, resulting in clinical and functional improvement. The patient was not followed up. In September 2013, he presented again with a 5-month history of dry cough and progressive dyspnea. He had discontinued prednisone prematurely, and against our advice, had started taking sulfasalazine again. Spirometry showed an obstructive ventilatory defect (FEV<span class="elsevierStyleInf">1</span>=905<span class="elsevierStyleHsp" style=""></span>ml [31% predicted]; FVC=1300<span class="elsevierStyleHsp" style=""></span>ml [34% predicted]; FEV<span class="elsevierStyleInf">1</span>/FVC=[69% predicted]). Arterial blood gases revealed hypoxemia, HRCT found bilateral areas of mosaic attenuation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and clinical laboratory results showed 1.9<span class="elsevierStyleHsp" style=""></span>g/l eosinophils in blood. Fiberoptic bronchoscopy showed hyperemia throughout the tracheobronchial mucosa, endobronchial biopsy found prominent eosinophil inflammation, and 32% eosinophils were seen on the bronchoalveolar lavage (BAL) leukocyte formula. Sulfasalazine was withdrawn, and the patient began treatment for HOB with 40<span class="elsevierStyleHsp" style=""></span>mg prednisone once a day and nebulized bronchodilators and corticosteroids, producing notable clinical and functional improvement. In November 2013, the patient's FEV<span class="elsevierStyleInf">1</span> was 2900<span class="elsevierStyleHsp" style=""></span>ml (114%) and FVC 3810 (105%). We recommended a gradual reduction over the course of several weeks of the initial dose of corticosteroids to the minimum maintenance dose for normal lung function and control symptoms. The patient also received formoterol/budesonide.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Cordier et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> recently characterized HOB as a new eosinophilic respiratory disease.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> These authors established 3 diagnostic criteria: (1) eosinophils in blood>1<span class="elsevierStyleHsp" style=""></span>g/l (and/or >25% eosinophils in BAL); (2) persistent airflow obstruction in lung function tests, with a post-bronchodilator FEV<span class="elsevierStyleInf">1</span>/FVC ratio<70% and FEV<span class="elsevierStyleInf">1</span><80% predicted, with no improvement after 4–6 weeks of treatment with inhaled corticosteroids (2000<span class="elsevierStyleHsp" style=""></span>μg/day beclomethasone or equivalent) − other functional parameters indicative of obliterative bronchiolitis are a decrease in forced expiratory flow between 25% and 75% of forced vital capacity (FVC) and an increase in the residual volume/total lung capacity ratio and (3) inflammatory bronchiolitis with significant eosinophilic infiltration on lung biopsy and/or signs of bronchiolitis on HRCT.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">HOB may be idiopathic, associated with asthma, or an integral part of an established disease (e.g., Churg–Strauss syndrome, hypereosinophilic syndrome, allergic bronchopulmonary aspergillosis, or adverse drug reaction).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> To date, no cases of drug-induced HOB have been reported. However, a report published some time ago described a 28-year-old man with minocycline-induced pulmonary eosinophilia. Cordier et al. reassessed this case and attributed it to possible iatrogenic HOB.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In our case, sulfasalazine was the etiological agent for this specific syndrome. While reports of drug-induced HOB in the literature are rare, specialists should be aware of this clinical entity, since early diagnosis is the mainstay of treatment.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Katsenos S, Antonogiannaki E-M, Psathakis K. Bronquiolitis obliterante hipereosinofílica inducida por sulfasalazina. Arch Bronconeumol. 2016;52:108.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1153 "Ancho" => 1626 "Tamanyo" => 158673 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">High resolution computed tomography of the chest in expiration, showing bilateral mosaic attenuation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypereosinophilic obliterative bronchiolitis: a distinct, unrecognized syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.F. Cordier" 1 => "V. Cottin" 2 => "C. Khouatra" 3 => "D. Revel" 4 => "C. Proust" 5 => "N. Freymond" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur Resp J" "fecha" => "2013" "volumen" => "41" "paginaInicial" => "1126" "paginaFinal" => "1134" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Obliterative (constrictive) bronchiolitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.P. Lynch" 1 => "S.S. Weigt" 2 => "A. DerHovanessian" 3 => "M.C. Fishbein" 4 => "A. Gutierrez" 5 => "J.A. Belperio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1055/s-0032-1325161" "Revista" => array:6 [ "tituloSerie" => "Semin Respir Crit Care Med" "fecha" => "2012" "volumen" => "33" "paginaInicial" => "509" "paginaFinal" => "532" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23001805" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute eosinophilic lung after a course of minocycline [article in French]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Dussopt" 1 => "J.F. Mornex" 2 => "J.F. Cordier" 3 => "J. Brune" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Mal Respir" "fecha" => "1994" "volumen" => "11" "paginaInicial" => "67" "paginaFinal" => "70" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8128099" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005200000002/v1_201601300120/S1579212915004310/v1_201601300120/en/main.assets" "Apartado" => array:4 [ "identificador" => "45358" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005200000002/v1_201601300120/S1579212915004310/v1_201601300120/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212915004310?idApp=UINPBA00003Z" ]
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