CASE REPORTS

TROPICAL EOSINOPHILIA IN CHILDREN*

WITII REPORT OF THREE CASES

NIVEDITA SEN

Calcutta

Trop ica l eos inophi l ia is one of the mo re r ecen t ly desc r ibed diseases. I t was first descr ibed by FRIMODT-IMOI.LER an d Ba•'rox in 1941), a ful ler accoun t be ing g iven by WEINOAR'rEI~ in 1943 who gave the disease its name . Since t h e n m a n y cases have been repor ted , by far the grea te r m a j o r i t y be ing f r o m various parts of Ind ia and C e y l o n ; a few f r o m o the r t ropica l count r ies and still fewer f r o m non- t ropica l countr ies .

T h r e e cases were seen in the ch i ld ren ' s ward of the L a d y Duffe r in Hospi ta l , Calcut ta , d u r i n g the year 1953 a n d 1954.

Case 1.--Johorlal, male, age 5 years. He was admitted on 19-2-53 with a history of pain in the abdomen, cough and fever off and on for a period of one month. On examination he was found to be well built and weli nourished. The lungs showed occasional scattered rhonchi. The liver and spleen were both palpable. The total W.B.C. count was 11,900; eosinophils 44 per cent and E.S.R. 51 ram. Radiological exami- nation revealed extensive coarse mottlings over both lung fields. The Mantoux Test was negative. FIe received 5 injections of ace@arsan but did not return to the hospital after discharge on 7-3-53.

Case 2.--Salma, female, age 6 years. This child was admitted on 26-9-53 with fever and cough for 2 months. She had diarrhoea and pain in the abdomen for 20 days. There was a history of previous asdamatic attacks. On examination she was found to be thin with enlarged lymph nodes. There were scattered rhonchi over both lung fields, with crepita- tions over the right lung and at the left base. The liver and spleen were not palpable. The total W.B.C. count was 16,700; eosinophils, 56 per cent; E.S.R. 48 ram., Kahn negative. Ascaris ova were present in the stools. On examination the chest showed extensive infiltrations in both lungs. The child was given santonin on 1-10-53. The blood on 9-10-53 showed 28 per cent eosinophils. The hmg signs persisted. Injections of acetylarsan, 2 cc. each bi-weekly, was started on 7-10-53. The blood on 5-11-53 showed 47 per cent eosinophils which decreased to 23 per cent before discharge. Ite received a total of 9 injections and the hmgs

* From the Lady Dufferin Hospital, Calcutta. Read at the Sixth All-India Pediatric Conference, Lucknow, February 23, 1955.

12O Indian Journal of Pedialrics

cleared up. The child was discharged well on 23-11-53 but did not re turn for follow-up.

Case 3. - -Mot i la l , male, age 8 ),ears was admi t t ed on 17-5-54, ~ i th cough and fever on and off for three years and occasional haemoptysis . He was a very thin child with enlarge~t l y m p h nodes in the neck. The lungs were clear ; the liver was palpable trot the spleen was nor felt. N o ova or cysts were found in the stools. Fu r the r investigations uere as follows: On 19-5-54 the total W.B.C. count was l l ,100/c .mm. ; eosino- phils 2 per cen t ; E.S.R. 47 ram. Rad iograms of the chest on 21-5-54 showed a coarse mot t l ing in broth upper and mid zones wbich was still present on 3-6-54. On 5-6-54 the cbild developed a cough with wheezing. Rhonchi were found in the hmgs.

On 14-6-54 the total Vq.B.C. count was 15,6(,R)/c.mm. and eosinophils were 60 per cent. The stools showed noth ing abnorlnal . X-ray of the chest wh id l was repeated on 14-7-54, showed extensive mot t l ing over both lung fields. On 17-6-54 acety!arsan uas started with weekly injec- tions. The eosinophils came down to 53 per cent on 15-7-54. T h e hmgs cleared up on 17-7-54. The child had received a total of 6 in jec t ions ; was discharged well but did not return.

The clinical features of a typical case as first described by WEtXC,Xa'rEN and confirmed later by other workers, namely TREU, R. N. CIIAUDtlURI, BALL, MIsRA, VlsHvr and others, are as follows. ~Ihe onset is insidious, with lassitude, loss of weight and fever in the evenings. About a week after, paroxysmal cough occurs followed by expiratory dyspnoea and scanty mucoid sputum. On examination of the lungs expira- tion is prolonged with sibilant rhonchi and crepitations like bronchial asthma, but with less rhonchi and more moist sounds. The general look of anxiety is also less. The blood shows a leucocytosis with eosinophilia above 20 per cent. The latter may be massive going up to 80-90 per cent. X'ray of the chest shows bilateral symmetrical mottling, each the size of a split pea present more towards the base and the hi lum. These last about four weeks and then disappear leaving behind increased markings of catarrhal broncl~itis.

The clinical features however, may not always be typical. Fever may not be present, or rarely may be the only complaint. The spleen may not be enlarged but the liver may be. The lymph nodes may be enlarged, this being common in children. The onset may be sudden and acute with some features of pneumonia or of bronchial asthma. There is no relation of the radiological changes with the severity of the clinical features. The latter may be, marked without any radiological changes, or sometimes the X ray changes may be marked without any

Tropical Eosinophilia in Children--Sen 121

chest complaints at all. Rarely the sputum may be streaked with blood or there may be haemopt-ysis. Rarely patches of pigmentation or purpuric rash on the skin may be t h e only complaint which clear up after treatment.

Substernal or vague abdominal pain may be present. Diarrhoea may be present without any chest complaint. Some- times signs and symptoms may shift from one system to another. Rarely there may not be any symptom at all, the disease being discovered accidentally by examination of the blood for some other reason. Eosinophilia in the blood is the basic change of the disease and is present in all cases, but this too in some cases may come down to normal for periods, during which other signs and symptoms may persist. Therefore, in cases where the disease IS suspected, the blood count should be repeated at intervals even though the earlier counts be normal. There is no relation of the seventy of signs and symptoms with the height of eosinophilia. Radiologica~i changes in the lungs may vary. BALL, most of whose cases were children, found the following variations--miliary mott!ing in 46 per cent ; increase of normal striations in 59 per cent and hilar gland enlargement m 46 per cent. This is more frequently present in children and is associated with one of the two other changes. No abnor- mality was detected in 6 per cent. The changes usually last about a month, but in some cases may remain much longer. In our series, Case 1 more or less conforms to the classical type. Case 2 and 3 belong to the atypical group, which is the corn- monet. Case 2 had enlarged lymph nodes without any enlarge- ment of the liver and spleen. Case 3 is of the comparatively rarer type having had a normal blood count at one time, followed by a severe eosinophilia after 3 weeks which was maintained. In this case, also, enlargement of the spleen was not present and the child had hemoptysis off and on.

LABORATORY FINDINGS

The most important is the change in the blood picture which is a teucocytosis with eosinophils above 20 per cent and often higher. The eosinophils are all mature cells. There is an increased E.S.R.. There is also an increase in the globulin fraction of the plasma protein while the albumin is normal or slightly diminished. The W.R. is positive in a large number of cases. Mites have been found in the sputum of some cases, but

122 Indian Journal of Pediatrics

they have also been found in the sputum of others not suffering from tropical eosinophilia.

Animal experiments were done by MISRA, VISWANATItAN and others, who reproduced the disease in animals by inocula- ting filtered sputum, whole blood or serum intraperitoncally into the animals.

The etiology of the condition is unknown. According to some it is an allergic condition like Loeffler's syndrome. Some think it may be due to allergy, or to worm infestation. But it has been found that giving vermifuge does not affect the clinical fea- tures, and that the rate of worm infestation is less in those with a higher degree of eosinophilia. Besides, worms are very common m tropical countries, very few of which are associated with tropical eosinophilia. The degree of eosinophilia in parasitic infestation is usually below 20 per cent. Mites have been found in the sputum of some of the cases in Ceylon, which were found to be destroyed by giving arsenic. But mites have also been found in the sputum of others in the sa~:,e locality not suffering from the disease. Some people think the disease is due to an infection. In fact, at the present time the general concensus of opinion is, that it is either an allergic condition, the allergen being unknown, or an infection. The occurrence of bronchial spasm, the arterial lesion and eosinophilia in the blood are in favour of allergy. While the occurrence of fever, positive W.R., increased E.S.R., increased globulin in the plasma, the dramatic response of the disease to organic arsenic and the fact that the disease has been reproduced by animal inoculation, is in favour of infection. The infection is probably by inhalation, which enters the peri-bronchial tissue, and sets up inflammation partly in the interstitial tissue, and partly in the alveoli. The allergic manifestations may be due to sensitivity to protein of the infecting organism. However, that is still to be proved.

Age Incidence. The disease occurs at all ages--the youngest seen being 1 year old and the oldest 87 years of age. About the maximum incidence opinion varies. Ball found it to be common in the age group of 14 years�9 and less. Others, whose cases were mainly adults, found the maximum incidence to be between 20 and 40 years. In our experience 3 cases were seen in the 1st decade, 1 in the 2nd, 1 in the 3rd, and 1 in the 4th decade, that is, it is apparently commoner in children.

The course is chronic, running for months or years. There is no mortality. Patients may recover spontaneously, though

Tropical Eosinophilia in Children--Sen 123

according to some workers the blood count never returns to normal without treatment. Under treatment with arsenic injec- tions the condition clears up rapidly, the blood count returning to normal in 6-8 months, a longer period being required in those with higher counts.

The pathological changes have been studied in cases who died from some other cause. Broncho-pneumonic patches occur in the lungs with infiltration of the interstitial tissue by eosino- philic cells. There is arteritis of the smaller blood vessels of vari- ous degrees going on to necrotizing artereolitis. In more chronic cases there is formation of nodules, which consists of groups of giant cells in the centre surrounded by a cluster of monocytes. These giant cells are different from those seen in tuberculosis. There appears to be be increased permeability of the vessel walls, which allows eosinophils to diffuse out into the interstitial tissue.

Diagnosis.--Eosinophilia is found in many diseases, but the only other condition which has sustained eosinophilia in the blood with lung infiltration is Loeffter's syndrome, which is much milder with no disturbance of general health, and the radiological changes in the lungs are flitting, rarely lasting longer than a week. Eosinophilia in the blood is not higher than 20 per cent. Some workers think that tropical eosinophilia and Loeffler's syndrome are variants, of the same disease, the differ- ence being in the degree of severit :,.

Treatment was accidentally ~liscovered by v~,rEINCARTEN, who gave arsenic to one of his cases who had syphilis as well, and found that it cured both. Arsenic is given as acetylarsan. The maximum dose is 2 cc. or less according to the age and body weight. 8-10 injections are given every 4-7 days. Arsenic can also be given by mouth as stovarsol, carbarsone or acetylarsan but thc effectiveness is less than when it is given parenterally. Aureomycin has been used with encouraging results in some cases. It is of particular value when the patient is sensitive to arsenic. But its use is still in the experimental stage.