pre-clinic conference: evaluation of peripheral eosinophila april 4-6, 2011 michael k mansour, md,...
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Pre-clinic Conference:Evaluation of Peripheral Eosinophila
April 4-6, 2011Michael K Mansour, MD, PhD
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Here’s a real case
• 35 yo presenting for routine primary care
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Review of Immune Cells
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Pathogen
Innate Immunity
Complete Immune Reaction
B/T cells
Draining Lymph nodes
AntibodyCytokine
Direct Killing
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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
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What accounts for the absolute number of eosinophils?
Stimulation
Production
Consumption
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• Medications– NSAIDs– Antimicrobials (PCN,
cephalosporin classes)– ASA– Beta-blockers
• Allergy– Asthma– Atopy– Nasal polyposis/ASA
sensitivity
Stimulation
Production
Consumption
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• 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
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• 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
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• 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
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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!
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• 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
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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….
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• 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