<30362EC6AFC1FD2DC3D6B5BFC3B62E687770>

Size: px

Start display at page:

Download "<30362EC6AFC1FD2DC3D6B5BFC3B62E687770>"

창정 여
6 years ago
Views:

1 대한내과학회지 : 제 76 권제 3 호 2009 특집 (Special Review) - 주요알레르기질환의진단과치료 호산구성폐렴의진단과치료 성균관대학교의과대학내과학교실삼성서울병원내과 최동철 Eosinophilic lung diseases: diagnosis & treatment Dong Chull Choi, M.D. Department of Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea The eosinophilic lung diseases include various pulmonary disorders linked by common finding of an increased peripheral or tissue eosinophils. During the past decades, there has been a rapid increase in the understanding of eosinophil biology. However, there is no consensus about the classification and optimal treatment for eosinophilic lung diseases. Better understanding of the factors that regulate eosinophil traffic in the lung will leads us to better understanding of eosinophilic lung diseases. (Korean J Med 76: , 2009) Key Words: Eosinophil; Eosinophilic lung diseases; Diagnosis; Treatment 서 Eosinophilic lung diseases ( 호산구성폐질환, 호산구성폐렴 ) 에는말초혈액혹은폐조직에서호산구의증가가관찰되는다양한폐질환들이포함된다 1, 2). 1950년대에호흡기증상과단순흉부방사선촬영상폐침윤이관찰되고말초혈액에서호산구가증가된경우 pulmonary infiltration with eosinophilia (PIE syndrome) 혹은 3, 4) pulmonary eosinophilia등의진단명이제안되어사용되어왔으나이후기관지폐포세척술과폐생검술이진단에이용되면서개개의질환의병리학적특징이밝혀지고새로운질환들이발견되면서분류법에도변화가일어나고있다. 1994년 Allen과 Davis 는현재까지알려진 eosinophilic lung diseases들을종합하여새로운분류를제안하였는데 1) 현재까지알려진다양한 eosinophilic lung disease 들을비교적잘분류하였다고생각되어 ( 표 1) 이를기준으로기술하고자한다. 론 Eosinophilic lung disease 의정의 Allen 과 Davis 는 eosinophilic lung disease 의진단기준으로 다음의세가지를제시하였는데 1) 이기준에따르면그동안보고된다양한질환들이거의포함된다. 첫째, 말초혈액의호산구가증가되어있으면서흉부 X- 선검사상폐침윤이관찰되는경우 (peripheral blood eosinophilia and chest X-ray infiltrates) 인데이기준에의하면과거 pulmonary infiltration with eosinophilia (PIE syndrome) 에해당되던질환들이모두포함될수있다. 두번째는말초혈액의호산구수의증가와상관없이폐조직검사상호산구의침윤이관찰되는경우이고세번째는기관지폐포세척액내에호산구의비율이증가한경우인데이두가지진단기준을적용하면병의초기에말초혈액에서호산구의현저한증가가관찰되지않는경우 5) 에도 eosinophilic lung disease 라는진단이가능하다. Eosinophilic lung disease 의종류 1. Simple pulmonary eosinophilia 과거의 Löffler s syndrome이나 PIE syndrome은폐침윤의원인이나폐조직의병리소견을고려하지않고임상증상,

2 - Dong Chull Choi. Eosinophilic lung diseases: diagnosis & treatment - Table 1 Classification of eosinophilic lung disease Classification of eosinophilic lung disease by Allen JN & Davies WB Simple Pulmonary Eosinophilia Chronic Eosinophilic Pneumonia Acute Eosinophilic Pneumonia Churg-Strauss syndrome Idiopathic Hypereosinophilic Syndrome Asthma Allergic Bronchopulmonary Aspergillosis Bronchocentric Granulomatosis Parasitic Infections Certain Drug Reactions adapted from Allen JN, Davis WB: Eosinophilic lung disease. Am J Respir Crit Care Med 150: , 1994 Figure 1. Acute eosinophilic pneumonia; chest PA. 말초혈액의호산구의증가, 흉부 X-선검사상의이동성의폐침윤이있는경우에임상적으로붙여진진단이다 6). 현재의기준으로본다면 simple pulmonary eosinophilia와기생충이나약제에의한일과성의폐침윤을보인증례들이포함되었으리라추측된다. 만약이런환자들중폐침윤의원인이기생충의감염이나약물에의한것으로밝혀지게되면 6) 이때는기생충이나약제에의한 eosinophilic lung disease라는진단명을사용하고원인이밝혀지지않은경우에만 simple pulmonary eosinophilia라는진단을내리는것이합리적이다. 단순흉부 X-선소견은일측성혹은양측성의일과성, 이동성폐침윤으로간질성및폐포성음영증가 (combined interstitial and alveolar consolidation) 를보이며폐주변부위에잘나타난다 7). 공동의형성, 늑막삼출, 임파선종대, 심비대등은관찰되지않으나 21) 간혹다발성의결절로나타나서악성종양의전이와유사한소견을보일수도있다 2). 고해상도단층촬영시에는음영증가부위 (consolidation) 나결절 (nodule) 주위에간유리음영 (ground glass opacity, halo) 을보일수있다 2). 일과성이어서조직검사를시행하는경우는드물고조직소견상폐포강 (alveolar space) 및폐포벽 (alveolar wall) 에호산구및조직구 (histiocyte) 의침윤이관찰된다 1). 특별한치료를하지않아도호전되는경우가많다. 2. Chronic eosinophilic pneumonia ( 만성호산구성폐렴 ) 장기간의치료를필요로하고재발이빈번하여예후가좋지않은질환이다. Carrington 등이 9명의환자를보고한이후에 10) 비로소별개의질환으로인정되어분류되게되었다 11). 증상은서서히시작되는데기침, 발열, 호흡곤란, 체중감소등이흔히나타나며객혈, 흉통, 근육통등은드물다 10). 40대여성에호발하며 10, 11) 의환자들중반수정도는기관지천식을가지고있는데이때천식의이환기간은 5년미만인경우가많다 11). 환자의 80% 이상에서말초혈액호산구수증가가관찰되며 IgE 항체는환자들중 2/3에서증가되어있다. 폐기능검사는초기에는정상이다가병이진행되면제한성환기장애를보이며폐쇄성환기장애소견을보이는경우도간혹있는데이는만성호산구성폐렴에병발된기관지천식에의한것으로생각된다 10). 단순흉부 X-선검사상가장특징적인소견은 photonegative pulmonary edema 라고부르는양측성, 폐주변부의심한침윤 (dense, extensive, bilateral, peripheral infiltrates) 이지만 10) 환자의반수이하에서만관찰된다 ( 그림 1). 그밖에결절성침윤, 음영증가 (consolidation), 공동형성, 늑막삼출등도나타날수있어다른질환들과감별이필요한경우도있다 1, 2). 조직소견상폐포및간질내의호산구와림프구의침윤이

- 대한내과학회지 : 제 76 권제 3 호통권제 583 호 2009 - 관찰되고폐포벽의비후 (alvelar wall thickening) 도관찰된다. 혈관염이나육아종의형성등은거의관찰되지않으며 30) 약 1/4의환자들에서는 bronchiolitis obliterans organizing pneumonia와유사한소견을보이기도한다 10, 11).

3 - 대한내과학회지 : 제 76 권제 3 호통권제 583 호 관찰되고폐포벽의비후 (alvelar wall thickening) 도관찰된다. 혈관염이나육아종의형성등은거의관찰되지않으며 30) 약 1/4의환자들에서는 bronchiolitis obliterans organizing pneumonia와유사한소견을보이기도한다 10, 11). 기관지폐포세척액내호산구의비율이 25% 이상으로증가되어있는경우가많으므로간질성폐질환의임상상을보이는환자에서기관지폐포세척액내호산구의비율이증가된경우에의심할수있다 12). 하루 30~40 mg의 prednisone으로치료하면 24~48시간후증상이호전되며흉부 X-선은 7~10일후호전되는데스테로이드를너무빨리중지하면대부분의환자에서재발하므로 5~20 mg의 prednisone을매일혹은격일로수개월간사용하여재발을억제하는것이좋다. 3. Acute eosinophilic pneumonia ( 급성호산구성폐렴 ) 1989년 Badesch 등은수일만의급격한발병과 1주일만의회복이라는급속한임상경과를보이면서경기관지폐생검상폐포강및폐포벽에호산구의침윤이관찰된증례를보고하면서 acute eosinophilic pneumonia 라는병명을사용하였다 13). 비록호산구성폐렴이라는병명을공통적으로사용하기는하지만현재까지알려진사실을종합하면급성호산구성폐렴은만성호산구성폐렴과는전혀다른질환으로생각된다. 기존의호흡기질환이없던사람에서대개 1~5 일간의발열이있으면서근육통, 흉통및저산소증을수반하는호흡부전 (hypoxemic respiratory failure) 를보이다가저절로혹은부신피질호르몬투여후에완전히회복되며재발하지않는다는특징을보인다 1). 단순흉부 X-선검사상초기에는미세한간질성의폐침윤이관찰되다가 2일이내에급격히진행되어폐포성및간질성의폐침윤이혼합되어나타난다 ( 그림 2). 전산화단층촬영에서는병의초기에는양측성, 미만성의망상성폐침윤 (bilateral, diffuse, reticular densities) 이관찰되며양측성, 반상의간유리음영 (bilateral, patchy ground glass opacities) 도관찰된다 2, 14). 발병기전으로 Badesch 등은과민반응의가능성을제시하였으나원인물질에대한언급은없었다 13). 최근 red spider에대한과민반응으로인하여발병하였다고추측되는증례와 15) 항우울제인 trazodone의과량복용후에발생한증례가보고되어 16) 적어도급성호산구성폐렴중일부는어떤항원에의하여발생하리라추측된다. Figure 2. Chronic Eosinophilic Pneumonia: Chest PA. 감염성폐질환과의감별이치료방침결정에매우중요하며실제로초기치료로항생제를사용한경우가많이보고되고있다. 흉부 X-선상급성호흡부전증후군과감별이어려운경우도많은데이런경우조기에기관지폐포세척술을시행하면급성호산구성폐렴의경우에는세척액내에서호산구의증가가현저한반면급성호흡부전증후군에서는호중구의증가가관찰되므로진단에도움이된다. 저산소증에대한산소흡입과심한경우에는단기간의전신적스테로이드사용을고려한다. 4. Idiopathic hypereosinophilic syndrome ( 특발성과호산구성증후군 ) Hypereosinophilic syndrome이라는병명은 1968년 Hardy 와 Anderson에의하여최초로사용되었다 17). 현재의진단기준은 18) 첫째 6개월이상지속되는말초혈액의호산구의증가 (1,500개/mm 3 이상 ), 둘째기생충감염이나알레르기질환등의호산구의증가를유발할수있는다른질환이없을것, 셋째장기침범의증거가있을것이며설사말초혈액내호산구수의증가가있더라도아무증상이없다면제외된다 19). 20세부터 50세사이의남자에호발하며워낙다양한임상상을보여원인및병태생리를밝히기가어렵고침범되는장기의빈도는보고마다약간의차이를보이지만대개혈액, 심혈관계, 피부, 신경계, 호흡기, 비장, 간, 안구, 소화기의순이다 19)

4 - 최동철. 호산구성폐렴의진단과치료 - 흔한증상은야간의발한, 식욕감소, 체중감소, 소양증, 기침, 발열등이며검사실소견으로는전체백혈구중 30~ 70%, 혈액 1 mm 3 당 10,000개이상으로호산구가증가되어있는것이특징적이다 20). 호흡기의침범은약 40% 의환자들에서관찰되는데객담을수반하지않는만성기침이가장흔한증상이고호흡기의이상은첫번째는심부전에의한 2차적인폐부종등에의하여, 두번째로는우심방에서발생한혈전에의한폐색전에의하여, 세번째로는호산구에의한직접적인폐침윤에의하여발생하리라추측되고있다 13). 초창기의보고들에서는흉막유출 (pleural effusion) 이가장흔한호흡기의이상소견으로환자들의반수에서관찰되며누출액 (transudate) 인경우가대부분이다 18). 14~28% 의환자들에서흉부 X-선상폐침윤이일어나는데폐침윤의양상은매우다양하여미만성 (diffuse) 혹은국소성의음영증가 (consolidation), 결절및결절주위의간유리음영을보일수있다 18). 전산화단층촬영상에서는반상의음영증가 (patchy consolidation) 혹은주위에윤륜 (halo) 을수반하거나수반하지않는결절로나타나기도하고마치폐부종과같이미만성의간유리음영을보이기도한다 2). 조직검사상폐실질에호산구의침윤이관찰되며간혹세동맥의호중구침유이관찰되기도하고만성적인경우에는섬유화의소견도보여만성호산구성폐렴과유사할수도있다. 기관지폐포세척액내호산구수도증가되는데다른 eosinohilic lung disease 에서도호산구수가증가될수있어서이것만으로감별진단은어렵다. 급성및만성호산구성폐렴, eosinophilic leukemia, 분선충 (Strongyloides stercoralis infestation) 의감염등을배제하여야하며호흡부전을일으키는경우는거의없다 21). 반수정도의환자들은스테로이드에반응이좋으며특히 IgE가증가된경우에반응이좋다고알려져있다. 1달간하루 60 mg의 prednisone을투여하고이후격일로 60 mg을투여하며반응하지않은경우에는 hydroxyurea, azathioprine, cyclophosphamide 등을투여할수있으며 PDGFR이양성인경우에는 Imatinib이효과적이라는보고도있다. 5. 알레르기성육아종증 (Churg-Strauss syndrome) 1951년 Churg와 Strauss 가최초로보고하였다 22). 1990년 American College of Rheumatology 에서는기관지천식, 말초혈액내호산구증가, 신경병증 (neuropathy), 이동성의폐침윤 (non-fixed pulmonary infiltrate), 부비동의이상, 조직소견상호산구의혈관외침윤 (extravascular eosinophils) 의여섯가지진단기준중네가지이상을충족하면진단이가능하다고제안하였다 23). 대부분의환자에서폐병변이발생하는데폐실질의침윤이가장흔한소견이고환자의약 1/3에서는늑막삼출이관찰된다 1, 2). 폐침윤은일시적이며반상 (patchy) 으로나타나는경우가가장흔하지만간혹양측성, 미만성결절로나타나서 Wegener s granulomatosis와비슷한양상을보이기도한다. Wegener s granulomatosis와의감별점은거의모든경우에기관지천식과말초혈액내호산구증가가동반되며폐병변이공동을형성하지않는다는점이다 24). 흉부방사선소견만으로만성호산구성폐렴과완전히감별할수없으며간혹병의초기에는만성호산구성폐렴양상을보이다가이후신경증상이현저해지면서알레르기성육아종증으로진단되는경우도있고저자도비슷한예를경험한바있다 25). 고해상도단층촬영상에서는간유리상의음영이관찰되는경우가가장흔하며중심부에중심소엽성의결절 (centrilobular nodule) 들을보이기도하고하부폐야의늑막하 (subpleural) 에주로분포하는음영증가 (consolidation) 도종종나타난다 2). 그밖에기관지벽의비후, 크기가비교적큰결절, 종격동의임파선종대, 늑막삼출및심낭삼출도관찰되며폐혈관염에의하여모양이불규칙적이거나별모양 (stellate) 의폐세동맥들 (pulmonary arteriole) 이폐실질내에서보이기도한다 26). 혈청에서 ANCA (antineutrophil cytoplasmic antibody) 가발견될수있는데, perinuclear pattern (p-anca) 이많고 ANCA 가음성인환자들에서비교적예후가좋다는보고가있다 27). Corticosteroid 및 azathoprine, hydroxyurea, cyclophosphamide 28) 등이치료에사용된다. corticosteroid의사용시에는경구로 1~2 mg/kg를투여하면서임상증상에따라감량하거나, 전신적인혈관염의치료에준하여 methyl-prednisolone의대량투여를시행하기도한다. 고용량의 corticoteroid 투여후천식증상및피부병변과호산구의증가는잘치료되지만, 신경계의증상은지속되는경우가종종있으며, 이런경우 cyclophosphamide의투여로효과를보는경우도있다 28)

- The Korean Journal of Medicine: Vol. 76, No. 3, 2009 - Table 2. Diagnostic features of allergic bronchopulmonary aspergillosis Clinical or labaratory findings Comments 1.

5 - The Korean Journal of Medicine: Vol. 76, No. 3, Table 2. Diagnostic features of allergic bronchopulmonary aspergillosis Clinical or labaratory findings Comments 1. Asthma wide range of severity 2. Chest roentgenographic infiltrate may be absent at initial stage 3. Immediate cutaneous reactivity to prick or intradermal; Aspergillus species essential for diagnosis 4. Elevated total serum IgE level useful in following disease activity 5. Precipitating antibodies to A.fumigatus may be seen in some normal individuals 6. Peripheral blood eosinophilia may be absent if patient has received oral corticossteroids 7. Elevated serum IgE or IgG to A.fumigatus essential for diagnosis 8. Central bronchiectasis virtually diagnostic for ABPA in absence of distal bronchiectasis; may be absent with ABPA-S * * ABPA-S: seropositive-allergic bronchopulmonary aspergillosis adapted from Rosenberg M, Patterson R, Minzer R, Cooper BJ, Roberts M, Harris KE: Clinical and immunologic criteria for the diagnosis of allergic bronchopulmonary aspergillosis. Ann Intern Med 86: , 1977 신경계, 심장, 소화기, 신장의침범이있는경우에는치료초기부터 Cyclophosphamide를투여하는것도고려할수있다 29, 30). 6. Allergic Bronchopulmonary Aspergillosis (ABPA) 1952년 Hinson 등에의하여최초로보고된이후 31) 많은증례들이보고되었고국내에서도몇예가보고되어있다. 그러나만성기관지천식환자의 1~2% 에서병발된다는주장 32) 을감안하면국내에도진단되지않은환자들이상당수있으리라추측된다. 임상양상에의한 8가지의진단기준이제시되어있으나 33) ( 표 2) 모든환자들에서관찰되지는않는다. 이진단기준중가장특이도가높은것은혈청내 aspergillus에대한특이적항체 (IgE 혹은 IgG) 의존재와흉부방사선소견상중심성의기관지확장증 (central bronchiectasis) 이다 32). 임상상은스테로이드의존성의중증천식을나타내는경우도있고비교적경증의천식을보이는경우도있다. 단순흉부 X-선소견으로는일시적인폐침윤, 중심성의기관지확장증, 확장된기관지벽의부종에의한기차길모양의음영 (tram-line shadow), 확장된기관지내에분비물이찬경우에보이는 gloved-finger 음영등을들수있고고해상도전산화단층촬영상 ( 그림 3) 에서는위의소견외에중심소엽성 (centrlobular) 결절과나뭇가지모양의음영등의세기관지염 (bronchiolitis) 소견도관찰된다 2). Figure 3. Chest HRCT of ABPA:. areas of parenchymal consolidation & central brochiectasis with mucoid impaction. ABPA에서의기관지확장증은다른원인으로인한기관지확장증보다광범위하고 (extensive), 폐의상부에많으며중심성이라는특징이있으나방사선소견만으로다른원인에의한기관지확장증과완전히감별할수는없다. 흡입스테로이드및전신스테로이드로치료한다. 7. 기생충 여러종류의기생충감염시에말초혈액이나폐실질내호산구의증가를동반하는폐침윤이발생할수있는데 ( 표 3) 1) 지역별로기생충감염빈도에차이가있으므로최소한우리나라에서보고된기생충성폐질환의임상양상은알아둘필요가있다

6 - Dong Chull Choi. Eosinophilic lung diseases: diagnosis & treatment - Table 3. Parasites causing eosinophilic lung disease Ancylostoma species Ascaris species Brugia malayi Clonorchis sinensis Dirofilaria immitis Ecchinococcus species Opisthorchiasis species Paragonimus westermani Schistosoma species Strongyloides species Toxocara species Trichnella species Wucheria bancrofti adapted from Allen JN, Davis WB: Eosinophilic lung disease. Am J Respir Crit Care Med 150: , 1994 회충은전세계인구의약 25% 가감염되어있으며특히후진국에서문제가된다. 충란을섭취하게되면소장에서부화하여유충이폐로이동하여성장한후다시소화기관으로이동하게되는데호흡기증상은유충이폐에서완전히성장하기전에나타나므로최초폐침윤이발생한후약 8주까지는대변검사상충란이검출되지않을수있다 1). 일시적인발열과기침이가장흔한증상이며흉부 X-선상폐말초부위에직경수 cm의이동성침윤으로나타난다 34). 폐흡충 (Paragonimus westermani) 감염은유병율과발생빈도가많이감소하기는하였으나아직도종종접할수있는질환이다. 폐침입단계에따라침윤성단계, 소결절단계, 섬유화, 석회화단계로나누어진다. 침윤성단계에서는폐로침입한유충이나충란이주위소동맥에염증이나혈전을일으키는데주로폐의중엽이나하엽에경계가불분명한폐포성경결병변으로나타나고이시기에는객담에서충란이검출되지않는다. 소결절단계에서는성충주위에낭종 (cyst) 이형성되어흉부 X선상주로폐말초부위의경한음영의단독소결절이나낭성공동으로보이는데이런낭성공동이특징적인소견으로 ring shadow, thin-walled cyst, cystic worm burrow 등의다양한명칭으로부른다. 섬유화단계에서는성충이죽은부위에증가된음영의섬유성소결절이나나타며주로하폐야에선상음영이나특징적인고리양음영 (ring shadow) 로나타난다. 석회화단계에 Table 4. Drugs causing eosinophilic lung disease Ampicillin Methylphenidate Beclomethasone dipropionate Minocycline Bleomycin Naproxen Carbamazepine Nickel Chlorpromazine Nitrofurantoin Clofibrate Para-aminosalicylic acid Cocaine (inhaled) Penicillin Cromolyn (inhaled) Pentamidine (inhaled) Desipramine Phenytoin Diclofenac Pyrimethamine Febarbamate Rapeseed oil Glafenine Sulfadimethoxime GM-CSF Sulfasalazine Ibuprofen Sulindac Interleukin 2 &3 Tamoxifen Iodinated contrast media Tetracycline L-tryptophan Tolazamide Mephenesin carbamate Tolfenamic acid Methotrexate Vaginal sulfonamide cream adapted from Allen JN, Davis WB: Eosinophilic lung disease. Am J Respir Crit Care Med 150: , 1994 서는원형혹은타원형의석회화음영이관찰된다. 이러한여러단계의음영이동시에다발적으로관찰되기도한다 35, 36). 고해상도전산화단층촬영상특징적으로직경 5~15 mm 의액체나가스를함유한낭종이관찰되며 37) 단순흉부촬영상관찰되지않던충낭및누로를발견할수있어진단에도움이되기도한다 38). 객담검사나피부반응시험으로진단할수도있으나효소면역진단법 (ELISA) 에의한특이적 IgG항체측정법이가장특이도와예민도가높으며치료하면약 6개월에서 1년에걸쳐서서히음전된다 35). 분선충 (Strongyloides stercoralis) 은열대및아열대지방에흔한기생충이지만 39) 우리나라에서도최초의보고이후 40) 여러예가보고되어있으며일단감염되면반복해서자가감염 (autoinfection) 을일으키고면역기능이저하되는경우에는치명적인 hyperinfection을일으킬수있어 39) 반드시감별이필요한질환이다. 자가감염이일어나면유충이모세혈관에서폐포강내로이동하면서폐렴 (inflammatory pneumonitis) 이나폐출혈을일으키는데이때흉부 X-선상서결절이나미만성의망상형침

7 - 대한내과학회지 : 제 76 권제 3 호통권제 583 호 윤 (diffuse reticular opacities) 으로나타난다. 대량감염이발생하면반상의폐포성침윤 (pachy alveolar consolidation) 이관찰되며이병변들은이동할수도있다 41). 또한폐의 hyperinfection시에는장내세균의감염이합병되고이로인하여폐농양을초래하기도한다 39, 41). 확진은대변이나객담내에서유충을발견하면가능하지만위음성인경우가많다. 외국에서는효소면역법에의한특이적 IgG항체의측정법을사용하고있으나 42) 국내에서는아직사용할수없다. 8. 약물 약물은 eosinophilic lung disease 를일으키는가장흔한원인중하나로 30가지이상이보고되어있다 ( 표 4) 1, 2). 임상양상은약물을중지하면저절로회복되는경증부터부신피질호르몬의투여를필요로할만큼중증까지다양하며 1, 2) 조직소견은폐실질내로호산구를비롯한다양한염증세포들의침윤이관찰된다 43). 흉부 X-선소견은원인약물에따라음영증가 (methotrexate, nitrofurantoin, salicylate, sulfonamide, penicillin 및항생제 ), 종격동임파성종대 (antiepileptics), 늑막삼출 (nitrofurantoin), 결절및망상의폐침윤 (methotrexate, nitrofurantoin) 등다양하게나타날수있으며 2, 43, 44) 고해상도단층촬영을시행하면병변의양상과정도를보다정확하게파악할수있다 2). 결 Eosinophilic lung disease 에는다양한질환들이포함된다. 비록 eosinophilic lung disease라는질환군에속한다고해도조직이나말초혈액에서의호산구의증가와폐침윤이라는점외에개개의질환간에원인이나병태생리의공통점이있다는증거는없어과연현재의분류가적절한지는분명하지않다. 향후개개의질환의발병원인과병태생리가규명되면보다체계적인분류와효과적인치료가가능하리라사료된다. 론 중심단어 : 호산구 ; 호산구성폐렴 ( 폐질환 ); 진단 ; 치료 REFERENCES 1) Allen JN, Davis WB. Eosinophilic lung disease. Am J Respir Crit Care Med 150: , ) Kim YK, Lee KS, Choi DC, Primack SL, Im GK. The spectrum of eosinophilic lung disease. J Comp Ass Tomog. 21(6):920-3, 1997ec 3) Reeder WH, Goodrich BE. Pulmonary infiltration with eosinophilia(pie syndrome). Ann Int Med 36: , ) Crofton JW, Livingstone JL, Oswald NC, Roberts ATM. Pulmonary eosinophilia. Thorax 7:1-35, ) 최동철, 안석진, 김호철, 천은미, 정만표, 권오정, 이종헌, 이경수, 한정호. 자연관해를보인전형적인급성호산구성폐렴 1 례. 알레르기 17:84-91, ) Ford RM. Transient pulmonary eosinophilia and asthma: review of 20 cases occurring in 5,702 asthma sufferers. Am Rev Respir Dis 93: , ) Citro LA, Gordon ME, Miller WT. Eosinophilic lung disease(or how to slice PIE). AJR 117: , ) Carrington CB, Adington WW, Goff AM, Madoff IM, Marjs A, Schwaber JR, Gaensler EA. Chronic eosinophilic pneumonia. N Eng J Med 280: , ) Liebow AA, Carrington CB. The eosinophilic pnemonias. Medicine 48: , ) Jerderlinic PJ, Sillician L, Gaensler EA. chronic eosinopphilic pneumonia: a report of 19 cases and review of the literature. Medicine 67: , ) Fox B, Seed WA. Chronic eosinophilic pneumonia. Thorax 35: , ) Speich R, Hess T, Krestin GP, Lagler U, Russi EW. The value of bronchoalveolar lavage for the diagnosis of eosinophilic pneumonias. Schweiz Med Wochenschr 122: , ) Badesch DB, King TE, Schwarz MI. Acute eosinophilic pneumonia: a hypersensitivi-ty phenomenon? Am Rev Respir Dis 139: , ) Cheon JE, Lee KS, Jung GS, Chung MH, Cho YD. Acute eosinophilic pneumonia: Radiographic and CT findings in six patients. AJR 167: , ) Godeau B, Brochard L, Theodorou I, Lebargy F, Aiache JM, Lemaire F, Schaeffer A. A case of acute eosinophilic pneumonia with hypersensitivity to red spider allergens. J Allergy Clin Immunol 95: , ) Salerno SM, Strong JS, Roth BJ, Sakata V. Eosinophilic pneumonia and respiratory failure associated with a trazodone overdose. Am J Respir Crit Care Med 152: , ) Hardy WR, Anderson RE. The hypereosinophilic syndrome. Ann Intern Med 68: , ) Chusid MJ, Dale DC, West BC, Wolff SM. The hypereosinophilic syndrome: Analysis of fourteen cases with review of the literature. Medicine 54:1-27, ) Weller PF, Bublet GJ. The hypereosinophilic syndrome. Blood 83: , ) Fauci AS, Harley JB, Roberts WC, Ferrans VJ, Granik HR, Bjornson BH: NIH conference: The idiopathic hypereosinophilic syndrome: clinical, pathologic, and therapeutic considerations. Ann Intern Med 97:78-92, ) Winn RE, Kollef MH, Meyer JI. Pulmonary involvement in

8 - 최동철. 호산구성폐렴의진단과치료 - the hypereosinophilic syndrome. Chest 105: , ) Churg J,Strauss L. Allergic granulomatosis,allergic angitis and periarteritis nodosa. Am J Pathol 27: , ) Masi AT, Hunder GG, Lie JT, Michel BA, Bloch DA, Arend WP, Calabrese LH, Edworthy SM, Fauci AS, Leavitt RY, Lightfoot RW, McShane DJ, Mills JA, Stevens MB, Wallace SL, Zvaifler NJ. The American Society of Rheumatology 1990 Criteria for Classification of Churg-Strauss syndrome. Arthritis Rheum 33: , ) Leavitt RY, Fauci AS. Pulmonary vasculitis. Am Rev Respir Dis 134: , ) 최동철, 고은미, 정만표, 김호중, 권오정, 이종헌, 한용철, 김병준, 한정호, 이병재. Cyclophosphamide 의간헐적대량투여로다발성단신경염의호전을보인알레르기성육아종증 1 례대한내과학회지 53(S): , ) Buschman DL, Waldron JA, King TE. Churg-Strauss pulmonary vasculitis. Am Rev Respir Dis 142: , ) Tervaert JWC, Limburg PC, Elema JD, Huitema MG, Horst G, The TH, Kallenberg CGM. Detection of autoantibodies against myeloid lysosomal enzymes: A useful adjunct to classification of patients with biopsy-proven necrotizing vasculitis. Am J Med 91:59-66, ) Genereau T, Lortholary O, Leclero P, Grenet D, Tubery M,S icard D, Caubarrere I, Guillevin L. Treatment of systemic vasculitis with cyclophosphamide and steroids: Daily oral low-dose cyclophophamide administration after failure of a pulse intravenous high dose regimen in four patients. Brit J Pharmacol 33: , ) Oh MJ, Lee JY, Kwon NH, Choi DC; Churg-Strauss syndrome: the clinical features and long-term follow-up of 17 patients. J Korean Med Sci. 21: , ) Solans R, Bosch JA, Perez-Bocanegra A, Selva A, Huguet P, Alijotas J, Orriols R, Armadans L, Vilardell M; Churg-Strauss syndrome:outcome of long-term follow-up of 32 patients. Rhematol 40: , ) Hinson KFW, Moon AJ, Plummer NS. Bronchopulmonary aspergillosis. A review and report of eight new cases. Thorax 7: , ) Ganz MA, Greenberger PA, Patterson R. Hypersensitivity pneumonitis and allergic bronchopulmonary aspergillosis. In Weiss EB, Stein M(eds): Bronchial asthma, 3rd ed. pp , Boston, Little Brown Co., ) Rosenberg M, Patterson R, Minzer R, Cooper BJ, Roberts M, Harris KE. Clinical and immunologic criteria for the diagnosis of allergic bronchopulmonary aspergillosis. Ann Intern Med 86: , ) Gelpi AP, Mustafa A: Ascaris pneumonia. Am J Med 44: , ) 이상도, 유철규, 한성구, 심영수, 김건열, 한용철, 김영환, 조승열. 폐흡충증의임상상및효소면역측정법의진단적가치. 대한내과학회잡지 37:71-80, ) Shim YS, Cho SY, Han YC. Pulmonary paragonimiasis: Korean perspective. Sem Respir Med 12:35-45, ) Im JG, Whan HY, Kim WS, Han MC, Shim YS, Cho SY. Pleuropulmonary paragonimiasis: radiologic findings in 71 patients. AJR 159:39-43, ) 임정기, 김상준, 한만청. 폐흡충증의방사선학적소견. 대한방사선의학회지 24: , ) Liu LX, Weller PF. Strongyloidiasis and other intestinal nematode infections. Infect Dis Clin North Am 7: , ) Kitamasa M. Experiment on Anguillula intestinalis, the causative agent for diarrhea in weatern Korea. J Chosen Med Ass 13:42-46, ) Woodring JH, Halfhill H, Reed JC. Pulmonary strongyloidiasis: clinical and imaging features. AJR 162: , ) Davidson RA. Infection due to Strongyloides stercoralis in patients with pulmonary disease. South Med J 85:28-31, ) Schwarz MI, King TE. Interstitial lung disease. 1st ed, pp , Philadelphia, Dekker, ) Amstrong P. Imaging of the diseases of chest. 2nd ed. pp , St.Louis, Mosby,

ÀÇÇÐ°�ÁÂc00Ì»óÀÏ˘

ÀÇÇÐ°�ÁÂc00Ì»óÀÏ˘ Common Allergic Diseases in Children Sang - Il Lee, M.D. Department of pediatrics Sungkyunkwan University School of Medicine, Samsung Medical Center E - mail : silee@smc.samsung.co.kr Abstract Allergy