Eosinophilic Pneumonia Associated With Natalizumab In A Patient With Multiple Sclerosis: A Case Report And Literature Review

Figures & data

Figure 1 A chest X-ray revealed patchy consolidation in the bilateral upper and left lower lung field (white arrow).

Figure 2 CT scans showed bilateral patchy consolidation surrounded by ground-glass opacity (white arrow).

Figure 3 BAL fluid showed increased numbers of eosinophils with Papanicolaou staining (A, ×400). Under high magnification, the eosinophils were stained light green with nuclear localization (B, ×800).

Figure 4 A chest X-ray and chest CT images showed an improvement in lung infiltrates after the discontinuation of natalizumab.

Figure 5 The clinical course of the patient.

Table 1 Laboratory Findings On The Initial Visit

Blood count			Biochemistry
WBC	13,500	/μl	TP	7	g/dl	PR3-ANCA	<0.1	U/mL
Neut	36.2	%	Alb	4.5	mg/dl	MPO-ANCA	<0.1	U/mL
Lymph	18.8	%	T-Bil	0.5	mg/dl	β-D-glucan	4	pg/mL
Mono	5.2	%	AST	17	IU/l	serum IgE	600.9	IU/mL
Eosino	38.7	%	ALT	22	IU/l
RBC	471×10^4	/μl	LDH	189	IU/l	Arterial blood gas test (room air)
Hb	13.5	g/dl	CK	77	IU/l	pH	7.424
Ht	41.4	%	BUN	9.3	mg/dl	PaO2	115	mmHg
MCV	88	fl	Cre	0.48	mg/dl	PaCO2	36	mmHg
MCHC	32.6	%	Glu	94	mg/dl	HCO3^−	23.1	mmol/l
Plt	25×10^4	/μl	Na	140	mEq/l
			K	4	mEq/l	Tumor marker
			Cl	107	mEq/l	CEA	1	ng/mL
			CRP	0.02	mg/dl	CYFRA	<0.5	ng/mL
			KL-6	130	U/mL	NSE	15.7	ng/mL
			SP-D	112	ng/mL

Table 2 Summary Of Cases With Respiratory Adverse Events Associated With Natalizumab

Reference	Respiratory Adverse Event	Age	Sex	Underlying Disease	Peripheral Blood Eosinophil	Eosinophil In BALF
^Citation11	NTM	28	F	RRMS	N/A	N/A
^Citation12	NTM	N/A	N/A	RRMS	N/A	N/A
^Citation13	Tb	45	F	RRMS	N/A	N/A
^Citation13	Tb	47	F	RRMS	N/A	N/A
^Citation14	PCM	46	M	RRMS	N/A	N/A
^Citation15	Sarcoidosis	38	M	CD	N/A	N/A
^Citation15	Sarcoidosis	37	M	CD	N/A	N/A
^Citation16	Suspected EP	41	F	RRMS	490/µL	12%
Our case	EP	39	F	RRMS	5520/µL	35%

Abbreviations: NTM, nontuberculous mycobacteria; RRMS, relapsing-remitting multiple sclerosis; N/A, not available; Tb: mycobacterium tuberculosis; PCM, paracoccidioidomycosis; CD, crohn’s disease.

de Masson A, Maillart E, Veziris N, Meyssonnier V, Papeix C, Caumes E. Cavitary pulmonary disease in a patient treated with natalizumab. Presse Med. 2014;43:1009–1012. doi:10.1016/j.lpm.2013.12.01224742610

 PubMed Web of Science ®Google Scholar

Hradilek P, Zeman D, Tudik I, Zapletalova O, Ulmann V. Asymptomatic lung disease caused by Mycobacterium kansasii as an opportunistic infection in a patient treated with natalizumab for relapsing-remitting multiple sclerosis. Mult Scler. 2014;20:639–640. doi:10.1177/135245851350157223959714

 PubMed Web of Science ®Google Scholar

Dahdaleh D, Altmann DM, Malik O, Nicholas RS. Breathlessness, night sweats, and weight loss on natalizumab. Lancet. 2012;380:726–727. doi:10.1016/S0140-6736(12)61401-922920745

 PubMed Web of Science ®Google Scholar

Almeida KJ, Barreto-Soares RV, Campos-Sousa RN, Campos-Sousa MG, Bor-Seng-Shu E. Pulmonary paracoccidioidomycosis associated with the use of natalizumab in multiple sclerosis. Mult Scler. 2018;24:1002–1004. doi:10.1177/135245851876309129649930

 PubMed Web of Science ®Google Scholar

Parisinos CA, Lees CW, Wallace WA, Satsangi J. Sarcoidosis complicating treatment with natalizumab for Crohn’s disease. Thorax. 2011;66:1109–1110. doi:10.1136/thx.2010.15576221233484

 PubMed Web of Science ®Google Scholar

Curto E, Munteis-Olivas E, Balcells E, Domínguez-Álvarez MM. Pulmonary eosinophilia associated to treatment with natalizumab. Ann Thorac Med. 2016;11:224–226. doi:10.4103/1817-1737.18576227512514

 PubMed Web of Science ®Google Scholar