A 42-year-old woman presents with a 3-month history of progressive dyspnea, persistent cough, and drenching night sweats with a 5 kg weight loss. She has a history of mild asthma. Chest X-ray shows bilateral peripheral consolidations sparing the central zones. Spirometry reveals the pattern marked **A** in the diagram. Laboratory investigations show absolute eosinophil count of 2800/μL and BAL eosinophils of 38%. Which of the following is the most appropriate next step in management?
A. Oral prednisolone 0.5 mg/kg/day with clinical reassessment at 48–72 hours
B. Antituberculous therapy pending sputum AFB results
C. Inhaled budesonide 400 μg twice daily with bronchodilator response testing
D. Transbronchial lung biopsy to exclude vasculitis before initiating steroids
Explanation
Why "Oral prednisolone 0.5 mg/kg/day with clinical reassessment at 48–72 hours" is right
The clinical presentation (subacute dyspnea, night sweats, weight loss, asthma history), imaging (bilateral peripheral consolidations), and the restrictive spirometry pattern marked A (reduced TLC, reduced DLCO, normal-to-increased FEV1/FVC ratio) combined with peripheral eosinophilia >1000/μL and BAL eosinophils >25% are diagnostic of chronic eosinophilic pneumonia (CEP). According to Carrington et al. (NEJM 1969) and the ATS/ERS Statement, oral prednisolone at 0.5 mg/kg/day produces dramatic clinical and radiological improvement within 48–72 hours and is the gold standard first-line treatment. The rapid response to steroids is so characteristic that failure to improve should prompt diagnostic reconsideration.
Why each distractor is wrong
Antituberculous therapy pending sputum AFB results: Although the presentation (fever, night sweats, weight loss, pulmonary infiltrates) may mimic tuberculosis, the combination of restrictive spirometry, elevated BAL eosinophils >25%, and peripheral eosinophilia >1000/μL is diagnostic of CEP, not TB. Starting anti-TB therapy would delay appropriate steroid therapy and is not indicated.
Inhaled budesonide 400 μg twice daily with bronchodilator response testing: While inhaled corticosteroids may be used as steroid-sparing agents in maintenance therapy after initial control, they are insufficient as monotherapy for acute CEP. The restrictive pattern and systemic symptoms require systemic corticosteroids for rapid response.
Transbronchial lung biopsy to exclude vasculitis before initiating steroids: Lung biopsy is rarely needed for CEP diagnosis when clinical, serological, and BAL findings are typical. The absence of systemic vasculitis features (no sinusitis, neuropathy, or ANCA positivity) and the characteristic BAL eosinophilia >25% make EGPA/Churg-Strauss unlikely. Biopsy would delay life-improving treatment.
High-YieldNEET PG
CEP (Carrington disease) = restrictive spirometry + reduced DLCO + bilateral peripheral consolidations + BAL eosinophils >25% → dramatic response to oral prednisolone 0.5 mg/kg/day within 48–72 hours.
Carrington CB et al., NEJM 1969; Marchand E et al., ERS Monograph; ATS/ERS Statement on Eosinophilic Pneumonia
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