What is the radiological presentation of eosinophilic pneumonia associated with Daptomycin (Cubicin, daptomycin)?

From the Guidelines

Daptomycin-induced eosinophilic pneumonia presents with a radiological picture of nonsegmental consolidation or ground-glass opacity that can be unilateral or bilateral, similar to the simple pulmonary eosinophilia pattern described in patients receiving molecular targeting agents and immune checkpoint inhibitors 1. The radiological findings in daptomycin-induced eosinophilic pneumonia can be characterized by:

• Bilateral peripheral ground-glass opacities and consolidations on chest imaging
• Infiltrates located in the mid to lower lung zones with a patchy or diffuse distribution
• Possible progression of radiological findings within days of daptomycin initiation
• Accompanying pleural effusions in some cases These changes are not specific to daptomycin-induced eosinophilic pneumonia and can resemble other types of pneumonia, making clinical correlation essential. The diagnosis should be suspected in patients on daptomycin therapy who develop new respiratory symptoms with compatible imaging findings, particularly those receiving doses >6 mg/kg/day or treatment beyond 2 weeks. Bronchoalveolar lavage typically reveals increased eosinophil counts (>25% of total cells), which helps confirm the diagnosis, similar to the pulmonary eosinophilia pattern seen in osimertinib therapy 1. The primary intervention is discontinuation of daptomycin, and the radiological abnormalities usually improve within 1-4 weeks after discontinuation, though complete resolution may take longer 1. Corticosteroids may accelerate radiological improvement in severe cases.

From the FDA Drug Label

Eosinophilic pneumonia has been reported in patients receiving daptomycin for injection [see Adverse Reactions (6. 2)] . In reported cases associated with daptomycin for injection, patients developed fever, dyspnea with hypoxic respiratory insufficiency, and diffuse pulmonary infiltrates or organizing pneumonia. The radiological picture of eosinophilic pneumonia associated with daptomycin includes diffuse pulmonary infiltrates or organizing pneumonia.

From the Research

Daptomycin Eosinophilic Pneumonia Radiological Picture

• The radiological findings of daptomycin-induced eosinophilic pneumonia (DIEP) include:
  • Bilateral opacities (68.1%) 2
  • Ground-glass opacities (41.7%) 2
  • Patchy infiltrates (30.6%) 2
  • Peripheral predominance (19.4%) 2
• Chest x-ray and CT scan findings are characteristic of DIEP, with pulmonary infiltration, ground glass opacity, or consolidation 3, 4, 5
• Radiological features are often accompanied by clinical symptoms such as fever, hypoxia, dyspnea, cough, and eosinophilia 6, 4

Diagnostic Criteria

• Diagnosis of DIEP is based on clinical, laboratory, and radiological evaluations, including:
  • American Thoracic Society (ATS) criteria 2
  • Phillips criteria 2
  • Lyon Algorithm 2
  • Bronchoalveolar lavage (BAL) findings, with an average eosinophil count of 28.6% (SD 24.4) 2

Treatment and Outcome

• Treatment of DIEP includes discontinuation of daptomycin, corticosteroids, and supportive measures such as supplemental oxygen 2, 3, 6, 4
• Recovery rates are high across all treatment types (≥ 73.7%) 2
• Most reports describe rapid improvement post-withdrawal of daptomycin (within 96 hours) 2