Acute eosinophilic pneumonia in a hookah smoker.

Acute eosinophilic pneumonia (AEP) is a hypoxic respiratory illness which manifests as fever, diffuse pulmonary opacities on imaging, and eosinophilia of greater than 25% on broncho-alveolar lavage (BAL), in the absence of a known cause for pulmonary eosinophilia. Though yet indefinite, an acute hypersensitivity reaction to an inhaled antigen could be the underlying trigger for AEP. Case presentation: 20-year-old male patient, regular hookah smoker, previously healthy, presented to the emergency department (ED) with a 3-day history of productive cough and worsening shortness of breath. In the ED, patient was febrile (T 103), tachypneic, tachycardic, and saturating well on room air. Electrocardiogram showed sinus tachycardia. Chest X-ray revealed bilateral airspace opacities with small effusions, suspicious for either pulmonary edema or bilateral pneumonia. He received intravenous (IV) hydration, and was started on empiric antibiotics with Ceftriaxone and Azithromycin, to cover for community acquired pneumonia. ED course was complicated by hypoxia on room air, requiring supplemental O2 by nasal cannula, after which he was admitted to the medical intensive care unit (MICU). In the MICU, he had worsening hypoxia necessitating use of a high flow nasal cannula and ultimately, intubation. An echocardiogram did not show any evidence of left sided dysfunction, with preserved ejection fraction and normal PAP. Respiratory cultures were negative. Patient was diagnosed with Acute Respiratory Distress Syndrome (ARDS). Ventilator settings were adjusted accordingly, and antibiotics were continued. Two days into admission, bronchoscopy was performed with (BAL), cell count of which revealed 56% eosinophils. He was thus diagnosed with acute eosinophilic pneumonia (AEP) and was started on IV Methylprednisolone, with subsequent improvement in condition. He was extubated successfully, transferred to the general ward, and discharged home shortly thereafter, in good condition. Discussion: AEP is likely an acute hypersensitivity reaction to an inhaled antigen, causing respiratory failure. Several studies have identified cigarette smoking as being such an antigen, with a significant association between the latter and AEP. Such an association is yet to be proven between AEP and hookah smoking. Here, we present the case of a young male patient, regular hookah smoker, but otherwise healthy, who was diagnosed with acute eosinophilic pneumonia and treated as such, with positive outcome. In conclusion, it is worthwhile to note that with the rise in hookah-smoking trend, an ARDS like picture in such patients, should raise concern for AEP