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 = – Moderate = – Severe = >5000
What accounts for the absolute number of eosinophils? Stimulation Production Consumption
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 – Wegeners 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 Pre Domestic USA trips 1987 (age 11) - United Kingdom, Ireland Bermuda (very bad diarrhea) Mexico, Jamiaca, Caymen Islands & Bahamas (cruise) New Mexico St. Maarten (spent a week), Germany Aruba (week) DC, Washington State, Alaska, Louisiana Utah, Nevada NC, TN, MS, AL, AR, GA HI, FL (Key West) St. Thomas, St. John, St. Lucia, Barbados, St. Maarten, Martinique (cruise but did eat in Barbados or Martinique) TX Mexico (Acapulco - week, got sick), Netherlands, Norway, Sweden, Denmark, Finland, Russia, Estonia CA, Greece --> got 'food poisoning' in Greece Ireland, ME DC, France, 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