MOFFITT AM REPORT PEARLS 7/19/16: Eosinophilia!

Thanks to Jesse for presenting the case of an elderly woman with fever, multiple rash morphologies, and eosinophilia! The kind of case where every consultant gets involved. Pearls below!

Definitions:

 

Eosinophilia: Absolute eosinophil count > 500

Hypereosinophilia: Severe eosinophilia >1500

Hypereosinophilic syndrome: Hypereosinophilia on at least 2 occasions with end-organ dysfunction due to eosinophilia

 

Does the degree of eosinophilia aid in diagnosis? Only if extreme!

– Very mild eosinophilia may be asthma/allergic

– Very severe eosinophilia (>20,000) likely myeloproliferative neoplasm (primary hypereosinophilic syndrome)

 

Think of these categories of disease for eosinophilia:

 

Allergic/Immunologic

– Atopic/Asthma

– Medication effect (e.g. DRESS/DIHS)

– Transplant rejection

– Vasculitis (e.g. Churg-Strauss)

– Immunodeficiency

 

Infectious

– Parasitic (strongyloides, toxocara, trichinella, schistosomiasis, filariasis, hookworm)

– Fungal infections (e.g. Aspergillus)

 

Heme/Onc

– Leukemia/Lymphoma

– Mastocytosis

– Primary hypereosinophilic syndrome (myeloproliferative neoplasm)

 

Adrenal insufficiency (relatively rare compared to other causes)

 

Other (diseases with specific organ involvement)

– Interstitial nephritis

– Eosinophilic pneumonia

– Many others including eosinophilic GI diseases

 

*Pearl: Giardia, malaria, and babesia do NOT typically produce eosinophilia!

*Pearl: Eosinophilia + Fever is NOT generally due to bacterial or viral infection! These LOWER eosinophil counts!

*Pearl: Tissue damage is more likely at eosinophil counts >1500, but can also occur at lower levels!

 

Recommended workup for unexplained eosinophilia:

– CBC, diff, blood smear

– Chem, u/a, LFTs

– Troponin (cardiac infiltration)

– Strongyloides serology

– Vit B12 (elevated in myeloproliferative neoplasm)

– Flow cytometry for lymphocyte subsets

– Chest Xray

– Serum tryptase (mastocytosis or hypereosinophilic syndrome)

 

Can also send if appropriate:

– Molecular testing for hematologic disorders

– Immunoglobulin levels (autoimmune disease or immunodeficiency)

– ANCA

– Morning cortisol

– Stool O&P

– Viral serologies (e.g. HIV, HTLV)

– Serologies for specific parasitic infections (e.g. schistosomiasis)

– CT, lymph node biopsy

 

Evernote: https://www.evernote.com/shard/s272/sh/c35ba2a4-0f49-4555-a1b7-fa99ad93a523/0c4c51dfcc3c2a672969957e5ce0c58d

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