1. Dr Rajesh Swarnakar MD,DTCD,DNB,FCCP(USA) Consultant Pulmonologist &Director Getwell Hospital & Research Institute, NAGPUR Raised Eosinophill Count : Clinical Significance

2. - Two-lobed, polymorphonuclear leukocyte 12 to 15 um diameter - Created by IL-3, Il-5 and GM-CSF -Three granule types, largest made up of MBP (major basic protein) - Kills Parasites, tumor cells, -Circulates <18 hours - 100-400 x more in tissues than in blood - Two-lobed, polymorphonuclear leukocyte 12 to 15 um diameter - Created by IL-3, Il-5 and GM-CSF -Three granule types, largest made up of MBP (major basic protein) - Kills Parasites, tumor cells, -Circulates <18 hours - 100-400 x more in tissues than in blood Eosinophil – our friend or foe ?

3. Can happen in Blood&Tissue Can happen in Blood&Tissue Bronchoscopy (BAL) EOS Percentage (%) rather than absolute number Normal volunteers = < 1% Raised Eosinophill Count : Blood Eosinophillia : Sampling peripheral blood Pulmonary Eosinophillia:Measured in BAL Eosinophils count: What’s Normal? Blood EOS (#) = up to 600/cmm

4. Eosinophil – associated diseases and disorders

5. The degree of Blood eosinophilia can be categorized into : Mild 500 to 1500 cells/microL Moderate 1500 to 5000 cells/microL Severe >5000 cells/microL Categories of Eosinophilia Peripheral eosinophilia can be divided into categories of, primary, secondary, or idiopathic eosinophilia

6. Eosinophils can also be seen in Hodgkin's and non Hodgkin lymphoma and other metastatic cancers, but the associated eosinophils are not of a clonal nature in this situation Primary eosinophilia Usually occurs in the context of hematologic malignancies, such as acute leukemias or chronic myeloid disorders, when there is evidence of clonal expansion of eosinophils The most common cause for secondary eosinophilia : is parasitic lung infection. Noninfectious causes of secondary eosinophilia include allergic disorders, medications, toxins, autoimmune diseases, and endocrine disorders such as Addison's disease.

7. A diagnosis of idiopathic eosinophilia is considered when a thorough evaluation does not identify either a primary or secondary cause of eosinophilia

8. Diseases Associated with Blood & Pulmonary Eosinophilia Pulmonary Eosinophilic Syndromes of Known Cause: Parasitic-induced eosinophilic pneumonias (including Loeffler’s syndrome) Drug-or toxin-induced eosinophilic pneumonias Tropical pulmonary eosinophilia Allergic bronchopulmonary mycosis. Pulmonary Eosinophilic Syndromes of Unknown Cause: Idiopathic acute eosinophilic pneumonia Chronic eosinophilic pneumonia Churg-Strauss syndrome (allergic granulomatosis and angiitis) Idiopathic hypereosinophilic syndrome

9. Interstitial lung disease -Idiopathic pulmonary fibrosis - Collagen-vascular disease associated -Sarcoidosis - Eosinophilic granuloma (pulmonary histiocytosis X) Malignancy -Non–small-cell cancer of lung -Non- Hodgkin’s lymphoma -Myeloblastic leukemia Miscellaneous (e.g., lung transplantation, ulcerative colitis Treatment of primary disease suffices to bring down raised eosinophil count. Bronchocentric granulomatosis Bronchiolitis obliterans- organizing pneumonia Infections – Fungal (esp.Coccidioidomycosis, Aspergillus,Pneumocystis jirovecii) -Tuberculosis Other Lung Diseases Variably Associated with Eosinophilia:Asthma/allergy

11. Algorithmic approach to evaluation patients with pulmonary/blood eosinophillia : ( Am J Respir Crit Care Med 150:1423- 138,1994.)

12. History & Physical Exam Collagen Vascular Disease HIV Risks Drugs Asthma History Travel History Stool Ova & Parasite Exam Strongyloides Ascaris Schistosoma Ancylosioma Pulmonary Function Tests Obstruction Non- Pulmonary Organ Involvement Pulmonary Involvement Only Churg-Strauss Chest x-ray Normal IgE < 1.000 Chest x-ray Abnormal IgE > 2.000 Asthma Allergic Bronchopulmonary Aspergillosis Bronchocentric Granulomatosis Restriction Bronchoalveolar Lavage Pneumocystis Strongyloides Aspergillus Cryptococcus > 20% Eosinophils< 20% Eosinophils Blood Eosinophil Count Interstitial Lung Disease Drug Reaction High ModerateLow/Normal Hypereosinophilic Syndrome Chronic Eosinophilic Pneumonia Simple Pulmonary Eosinophilia Acute Eosinophilic Pneumonia

14. CEPABPACSSHIS SubacuteAcute, subacute, chronic Subacute, chronic + (30 – 60 %)Nearly 100%100%- Mild – mod. In mostTypicalExtreme, fluctuatingExtreme, persistent StrikingIn someProminentStriking Mod. –elev. In 30%Marketed elev., fluctuates w/disease Mod. –elev.Mod. –elev. In some UnknownAspergillus (or other fungus) Unknown Predominately, peripheral consolidation and GGOs “photographic negative of pulmonary edema” Upper lobe predominant proximal bronchiectasis Transient. Migratory peripheral, rarely diffuse: patchy peribronchial and septal thickening, patchy parenchymal GGO or consolidation Transient, focal or diffuse Normal. OVD, or RVDOVD +/- RVD Mild RVD in some NoneSee Table 72 – 4Histopathology plus appropriate clinical setting Extreme persistent eosinophilia and multi- organ dysfunction (no other evident cause) Occasionally mild, non – necrotic NoneCharacteristic (see text)None Very rare reportedNoneTypical of vasculitic phaseCardiac, neurological. GI, hematological, other CorticosteroidsCorticosteroids, bronchodilators, antibiotics, antifungals Corticosteroids, other immunosuppressive (see text) CommonTypicalInfrequent after RxChronicity typical

15. Thank you for your Kind attention This presentation is available on www.lungscare.com/ppt Email : drrajeshswarnakar@gmail.com

16. 1 st -2 nd February, 2014 Hotel Hyatt Regency, Pune, India International Conference on Insights and Management of COPD On behalf of the organising committee, it gives us immense pleasure to welcome you to the first international conference on COPD – ICONIC 2014, to be held on 1 st and 2 nd February, 2014 at “Hotel Hyatt Regency”, Pune. The scientific programme will cover insights on the burden, pathophysiology, risk factors for COPD, advances in disease management and new directions for research in COPD, and a discussion on the much needed policy change in the management of COPD practices in India. Come listen to some of the internationally acclaimed leaders in Respiratory Medicine from across the globe including Prof. P. J. Barnes, Prof. James Hogg, Dr. John Walsh, Dr. Robert A. Wise, Dr. Sonia Buist, Dr. John R. Balmes and others. Once again we extend a cordial welcome to you all and look forward to your active participation in ICONIC – 2014!!! Dear friends and colleagues, Organizing committee office: Chest Research Foundation, Kalyani Nagar, Pune 411014, INDIA Secretariat contact: Telephone (Contact): +91 22 2494 0518 Fax: +91 22 2494 0517 Email: secretariat@iconic2014.com Website: : www.iconic2014.com ICONIC - 2014 Organized by: Chest Research Foundation, India and Johns Hopkins University, USA ICONIC is Endorsed by: