Multiple lung nodules, eosinophilia and severe asthma

We present an unusual clinical scenario of a severe asthmatic with persistent eosinophilia and multiple peripheral pulmonary nodules. Biopsy of these nodules was consistent with a diagnosis of angiolymphoid hyperplasia with eosinophilia (ALHE). ALHE is a rare condition that usually affects women and commonly affects subcutaneous tissues of head and neck. Only a handful of cases have reported pulmonary involvement. To our knowledge, this is the first case of pulmonary ALHE that has been treated with benralizumab, an anti-interleukin-5 receptor alpha monoclonal antibody, which resulted in improvement in symptoms as well as airway and blood eosinophilia and had a modest effect on the size of the pulmonary nodules. We also highlight a novel imaging finding of beading and focal nodular dilation of sub-segmental branches of pulmonary arteries, which could reflect proliferation of small-caliber vessels and hyperplastic endothelial lining seen on histopathology.