Pre-clinic Conference:Evaluation of Peripheral Eosinophila

April 4-6, 2011Michael K Mansour, MD, PhD

Here’s a real case

• 35 yo presenting for routine primary care

Review of Immune Cells

Pathogen

Innate Immunity

Complete Immune Reaction

B/T cells

Draining Lymph nodes

AntibodyCytokine

Direct Killing

When are you concerned?

• Eosinophilia represents a large spectrum of disease

• Benign finding to life-threatening disease state

• Definition of clinically significant eosinophilia based on absolute number:– Mild = 500-1500– Moderate = 1500-5000– Severe = >5000

What accounts for the absolute number of eosinophils?

Stimulation

Production

Consumption

• Medications– NSAIDs– Antimicrobials (PCN,

cephalosporin classes)– ASA– Beta-blockers

• Allergy– Asthma– Atopy– Nasal polyposis/ASA

sensitivity

Stimulation

Production

Consumption

• Viruses– HIV– HTLV-1

• Bacteria– Bartonella (cat-scratch

fever)– Tuberculosis– Leprosy– Resolving scarlet fever– Syphilis

Stimulation

Production

Consumption

• Fungi– Coccidomycoses– Aspergillus (ABPA)

• Parasites– Key is tissue invasion– Over 400 species – Strongyloides– Hookworm (Ancylostoma)– Schistosomiasis – Toxocara– Isopora– Dientamoeba

• Disorders of bone marrow production– Hypereosinophilic

syndrome– Mastocytosis

• Malignancy– Lymphoma (Hodgkin)– Leukemia (CEL)– Multiple solid tumors– Thymoma– Related to IL-5

production

Stimulation

Production

Consumption

• Rheumatologic– Churg-Strauss syndrome– Wegener’s

granulomatosis– HyperIgE, facial

deformities, dermatitis

• Loss of eosinophils related to apotosis

• Downregulation of IL-5• Glucocorticoids key

regulators of apotosis• Steroid deficient states

allow prolonged survival of eosinophils

Stimulation

Production

Consumption

Evaluation…..is a journey; first phase

• Infectious Diseases– Microbiology evaluation

• 3 stool samples for O&P (2 at MGH >90% sensitivity)

• Specific serology for globe-specific travel

• HIV, Trep-sure, TST

• First question you ask is….have you traveled?

• Allergy– Review medications– Seasonal allergy– Atopy– Environmental testing– PFT

YES! NO!

• More rare diagnosis– Adrenal insufficiency

• Higher suspicion if physical suggests AI• Vitals and routine blood work

• Malignancy– Non-resolving eosinophilia– Would need bone marrow evaluation

• Rheumatologic disorders maybe life-threatening– Always rely on physical exam to allow you the luxury of time– Keep an eye on end-organ damage– HES may have severe cardiac involvement with minimal

peripheral eosinophilia

Evaluation…..is a journey; second phase

Travel history -1987 - 1987 Pre Domestic USA trips( 11) - , 1990 - age United Kingdom Ireland Bermuda( ) 1991 - , , very bad diarrhea Mexico Jamiaca

( ) 1992 - Caymen Islands & Bahamas cruise New 1994 - . ( ), Mexico St Maarten spent a week

1997 - ( ) 2000 - , Germany Aruba week DC , , 2001 - , Washington State Alaska Louisiana Utah

2002 - , , , , , 2003 - , Nevada NC TN MS AL AR GA HI FL( ) 2004 - . , . , . , Key West St Thomas St John St Lucia

, . , ( Barbados St Maarten Martinique cruise but did )2005 - 2006 - eat in Barbados or Martinique TX

( - , ), , Mexico Acapulco week got sick Netherlands, , , , , Norway Sweden Denmark Finland Russia 2007 - , --> ' ' Estonia CA Greece got food poisoning

2008 - , 2009 - , , in Greece Ireland ME DC France 2010 - . , , Italy St John FL UT

Our case….

• Eosinophilia represents a spectrum of disease• Think of ABSOLUTE numbers (>400)• First line question is “have you traveled?”• The work-up may be a long journey• Ask you friendly subspecialty colleagues for help !• Any sign of end-organ involvement should prompt a

more rapid work-up

Take Home Messages