TROPICAL EOSINOPHILIA

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TROPICALEOSINOPHILIA

• Dr. S. Todd Stephens
• INMED International Medicine Intensive Course
• June 1, 2009

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EOSINOPHILS

• Eosinophils are tissue-dwelling cells
• can have eosinophilia of blood, sputum, urine,
  CSF, pleural/peritoneal fluid, etc.

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EOSINOPHILIA

• 2nd most common hematologic abnormality
• in tropics
• among immigrants and returning travelers (esp.
  VFR).

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EOSINOPHILIA

• Defined as
• Absolute eosinophil count
• 450-500 eosinophils/ul
• Diurnal variation
• affected by steroids, estrogen, and epinephrine.

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Major causes of eosinophilia

• Reactions to drugs
• Connective tissue diseases
• Hypereosinophilic syndromes
• Infections, parasitic
• Neoplasia
• Allergic conditions, Addisons disease

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Drug-induced Eosinophilia

• Allopurinol (hypersensitivity vasculitis,
  interstitial nephritis)
• Aspirin (asthma, nasal polyps)
• Sulfonamides (pulmonary infiltrates)
• Nitrofurantoin (pulmonary infiltrates)
• Penicillins (asymptomatic, dermatologic
  manifestations, interstitial nephritis)
• Cephalosporins (idem)

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Drugs (contd)

• L-tryptophan (Eosinophilic myalgia syndrome)
• Phenytoin (hypersensitivity vasculitis)
• Dantrolene, Bleomycin, Methotrexate
  (pleuropulmonary manifestations)
• NSAIDS (pulmonary infiltrates, GEitis)

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Connective tissue disorderswith eosinophilia

• Rheumatoid arthritis usually eosinophilia only
  in seropositive RA patients with
  pleuro-pericardial involvement
• SLE
• Churg-Strauss syndrome (CSS)
• Crohns and Ulcerative Colitis
• Polyarteritis nodosum
• Eosinophilic fasciitis, cellulitis, and
  panniculitis

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Hypereosinophilic syndrome

• Diagnosis of exclusion (no identifiable cause)
• Absolute eosinophils gt 1,500/ul x 6 months
• Assoc. with anemia/thrombocytopenia and abnormal
  eosinophil morphology
• Constitutional symptoms (fever, wt. loss, night
  sweats)
• CNS, heart, lung, kidney involvement

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Neoplastic diseaseswith eosinophilia

• Hodgkins lymphoma
• Mycosis fungoides (T-cell)
• Acute leukemias
• Malignancies of lung, stomach, pancreas, ovary or
  uterus
• Malignant mast cell disease histiocytosis

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Allergic diseasewith eosinophilia

• Allergic rhinitis/sinusitis
• Asthma
• Atopic dermatitis

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Addisons disease

• Adrenal insufficiency

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Parasitic Infectionswith eosinophilia

• Protozoa (Isospora belli, Toxo, Sarcocystis)
• Bacterial (Chronic tuberculosis)
• Fungal (Coccidiomycosis, Aspergillosis-ABPA)
• Scabies, myiasis
• Helminths (by far the most common!)
• Nematodes (round worms)
• Trematodes (flukes)
• Cestodes (tapeworms)

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Helminthic Infections with eosinophilia

• Nematodes (round worms)
• Pin worms (enterobiasis) and Whip worms
  (trichuriasis) do NOT
• Strongyloides
• Ascariasis
• Hookworms
• Visceral or Cutaneous larval migrans
• Trichinosis
• Filariasis, lymphatic
• Loa loa
• Onchocercosis,

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SIX MOST COMMON HELMINTHIC CAUSES OF EOSINOPHILIA

• Ascariasis (A. lumbricoides)
• Cutaneous larva migrans (Ancylostoma braziliense)
• Filariasis (Wuchereria bancrofti)
• Hookworm disease (Ancylostoma duodenale, Necator
  americanus)
• Strongyloidiasis (S. stercoralis)
• Schistosomiasis

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EOSINOPHILIA

• Is the absolute eosinophil elevated?
• Is eosinophilia related to the patients travel or
  symptoms?
• If travel related, what parasites are likely?
• What is the best approach to determine the cause
  of travel-associated eosinophilia?

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Is the absolute eosinophil count elevated?

• Is the absolute count gt450-500/ul?
• Is it
• Mild (450-1000/ul)
• Moderate (1000-2000/ul)
• Marked (gt3000/ul)

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Is Eosinophilia Related to Patients Travel?

• Complete travel history
• Review pre-travel CBC/diff
• Rule out underlying allergic disease
• Recent drug/supplement use?
• Are there associated symptoms?

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If Travel Related, Which Parasitic Disease is
Likely?

• Does your history and physical exam direct you to
  specific organ-system related signs and symptoms?
  

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Which parasitic diseases are likely?History

• Geography
• Exposure history
• Urban vs. rural vs. adventure travel?
• Walked barefoot?
• Fresh water exposure?
• Dietary history (pork? Suspect foods?
• Mosquito net/repellent use?
• Duration of stay

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Which parasitic diseases are likely? Physical
Exam

• CNS space-occupying lesions?
• Echinococcus species
• Cysticerca cellulosae
• Schistosoma species
• Paragonimus westermani
• Trichinella spiralis
• Dracunculus mediensis

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Which parasitic diseases are likely? Physical
Exam

• Pulmonary ?
• Ascaris lubricoides
• Ancylostoma duodenale
• Necator americanus
• Strongyloides stercoralis
• Toxocara canis (dog ascarid)
• Paragonimus westermani (lung fluke)
• Schistosoma species
• Echinococcus (hydatid cyst disease)
• Microfilarie

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Which parasitic diseases are likely? Physical
Exam

• Gastrointestinal?
• Ascaris lumbricoides
• Taenia solium
• Ancylostoma duodenal
• Taenia saginata
• Necator americanus
• Trichuris trichiura
• Strongyloides stercorali
• Enterobius vermicularis
• Toxocara canis
• Fasciolopsis bushki
• Schistosoma mansoni S. japonicum, S. mekongi

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Which parasitic diseases are likely? Physical
Exam

• Liver?
• Echinococcus granulosus,
• E. multilocularis
• Toxocara canis, T. cati
• Schistosoma mansoni, S. japonicum, S.
  mekongi
• Fasciola hepatica

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Which parasitic diseases are likely? Physical
Exam

• Urinary?
• Schistosoma haematobium

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Which parasitic diseases are likely? Physical
Exam

• Muscle?
• Trichinella spiralis

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Which parasitic diseases are likely? Physical
Exam

• Skin?
• Onchocerca volvulus (River blindness)
• Cysticerca cellulosae
• Loa loa
• Ancylostoma brasiliensis (CLM)
• Dracunculus mediensis (Guinea worm)

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What is an appropriate laboratory workup for
unexplained eosinophilia?

• Step 1
• CBC/diff , CMP, repeat eosinophil count
• Stool for OP x 3 (direct and conc.)
• Urinalysis, (casts? stain for eosinophils) and
  urine OP

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Other additional labs if indicated by signs or
symptoms

• Step 2
• CXR (hydatid dz, paragonimiasis, TPE)
• LP (CNS strongyloides, Cocciodio)
• Skin snips (Onchocerca)
• Soft tissue x-ray (Trichinosis)
• Sputum for OP (paragonimiasis)
• Abdominal ultrasound (hydatid dz)
• Rectal snips cystoscopy (Schistosomiasis)
• Liver biopsy lung biopsy

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Appropriate laboratory work-up for eosinophilia?

• Step 3
• Serologies (six most common)
• Strongyloides
• Schistosoma
• Echinococcus
• Toxocara
• Trichinella
• Filaria (alt. night blood smear)
• (http//www.dpd.cdc.gov/dpdx/HTML/DiagnosticProced
  ures.htm for serology)

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Antibody Antigen detection serologies available
at CDCDiseaseOrganismTest

• AmebiasisEntamoeba histolytica Enzyme immunoassay
  (EIA)
• BabesiosisBabesia microti Babesia sp. WA1
  Immunofluorescence (IFA)
• Chagas diseaseTrypanosoma cruzi IFA
• CysticercosisLarval Taenia solium Immunoblot
  (Blot)
• EchinococcosisEchinococcus granulosus EIA, Blot
• Leishmaniasis Leishmania braziliensis L. donovani
  L. tropica IFA
• Malaria Plasmodium falciparum P. malaria P. ovale
  P. vivax IFA
• ParagonimiasisParagonimus westermani Blot
• SchistosomiasisSchistosoma sp. S.  Mansoni S.
  haematobium S. japonicum FAST-ELISA Blot

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Antibody Antigen detection serologies available
at CDCDiseaseOrganismTest

• Strongyloidiasis Strongyloides stercoralis EIA
• Toxocariasis Toxocara canis EIA
• Toxoplasmosis Toxoplasma gondii IFA-IgG, EIA-IgM
• Trichinellosis (Trichinosis)Trichinella spiralis
  EIA
• African trypanosomiasis
• Filariasis
• Angiostrongylus
• Anisakis
• Baylisascaris procyonis
• Echinococcus multilocularis
• Fasciola hepatica
• Gnathostoma

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Is empiric therapy warranted?

• Not uncommon for no cause to be found for
  eosinophilia!
• Most parasitic infections are self-limited
• morbidity is related to worm burden.

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If clinically stable

• 3-6 mos trial of observation with no treatment
  and retresting, or
• Therapeutic trial of
• albendazole (or thiabendazole), plus
• praziquantal.

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empiric therapy

• Albendazole 400mg/day for 3 days
• 400mg x 1 dose is tx for Ascaris, Hookworms, CLM,
  ( whipworms, and pinworms.)
• 400 mg x 3 days is tx for Strongyloides and
  (probably) VLM (although 400 mg BID x 5 days is
  formally recommended)
• Cost 19.68
• Praziquantal 40mg/kg one dose (or 20mg/kg bid)
  goes by the name of Biltricide. directed against
  Schistosomiasis.
• Cost 74 (Walmart).

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• Thank you for your attention.
• The end.