Clinical presentation

A 33-year-old Japanese man experienced intermittent severe epigastralgia 5 days before admission followed by dyspnoea and fever, and he was hospitalised in acute respiratory failure. He had taken no medications before admission. Bilateral ground-glass opacities were seen on the chest radiograph on admission. The patient received BCG in childhood and had no history of atopy, asthma or any allergies, and did not smoke. On examination, his body temperature was 38.3°C, and oxygen saturation on air was 88%. Mild fine inspiratory crackles were detected by chest auscultation. There were no signs of urticarial rash or angioedema. He had epigastric tenderness without signs of peritoneal irritation.

Laboratory tests revealed the following: white blood cell count, 1.26×10⁹/l; proportion of peripheral eosinophils, 2.3% (normal …