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A 42-year-old man with a history of asthma has increasing shortness of breath and wheezing. He also is complaining of a cough for the past 2 weeks. Furthermore, he notes that he has had difficulty walking because his right foot seems to œdrop. He is on low-dose steroids that were discontinued recently when he was started on inhaled steroids. He is also on a variety of inhalers, including albuterol, ipratropium, and salmeterol. He has no allergies. His temperature is 38.3 C (101.0 F) and other vital signs are stable. Pulmonary examination reveals mild crackles on the left and occasional wheezing. Chest x-ray shows patchy opacities. His leukocyte count is 13,000/mm3 with 15% eosinophils. Urinalysis is unremarkable. Which of the following is the most likely diagnosis?

A. Bacterial pneumonia
B. Churg-Strauss syndrome
C. Goodpasture syndrome
D. Sarcoidosis
E. Wegener granulomatosis

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B.

The correct answer is B. The combination of eosinophilia, asthma, and neuropathy leads to a diagnosis of Churg-Strauss syndrome. It is likely that cessation of steroids unmasked the syndrome. Treatment includes high-dose steroids or other immunomodulators.

Although the patient has a fever and shortness of breath, the presentation is inconsistent with pneumonia (choice A).

The normal urinalysis indicates that this is not a pulmonary-renal syndrome, but this should be considered if the patient does not improve (choice C).

The patient does not have hilar adenopathy. Also, eosinophilia is atypical in sarcoidosis (choice D).

Wegener granulomatosis (choice E) is also a pulmonary-renal syndrome. Often the antinuclear cytoplasmic antibody is positive.