Dr Rajesh Swarnakar MD,DTCD,DNB,FCCP(USA) Consultant Pulmonologist &Director Getwell Hospital & Research Institute, NAGPUR Raised Eosinophill Count : Clinical Significance
Jan 26, 2016
Dr Rajesh SwarnakarMD,DTCD,DNB,FCCP(USA)
Consultant Pulmonologist &Director
Getwell Hospital & Research Institute, NAGPUR
Raised Eosinophill Count :
Clinical Significance
•
--Two-lobed, polymorphonuclear leukocyteTwo-lobed, polymorphonuclear leukocyte 12 to 15 um diameter 12 to 15 um diameter
- Created by IL-3, Il-5 and GM-CSF - Created by IL-3, Il-5 and GM-CSF -Three granule types, largest made up of MBP (major -Three granule types, largest made up of MBP (major basic protein)basic protein)
- Kills Parasites, tumor cells, - Kills Parasites, tumor cells, -Circulates <18 hours-Circulates <18 hours- 100-400 x more in tissues than in blood- 100-400 x more in tissues than in blood
Eosinophil – our friend or foe ?
Can happen in Blood&TissueCan 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
Eosinophil – associated diseases and disorders
The degree of Blood eosinophilia can be categorized into :
Mild 500 to 1500 cells/microL
Moderate 1500 to 5000 cells/microL
Severe >5000 cells/microLCategories of Eosinophilia
Peripheral eosinophilia can be divided into categories of ,
primary, secondary, or idiopathic eosinophilia
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.
A diagnosis of idiopathic eosinophilia is considered when a thorough evaluation does not identify either a primary or secondary cause of eosinophilia
Diseases Associated with Blood & Diseases Associated with Blood & Pulmonary EosinophiliaPulmonary 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
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
Algorithmic approach to evaluation patients with pulmonary/blood eosinophillia :
( Am J Respir Crit Care Med 150:1423-138,1994.)
History & Physical Exam
Collagen Vascular DiseaseHIV RisksDrugsAsthma HistoryTravel History
Stool Ova & Parasite ExamStrongyloidesAscaris SchistosomaAncylosioma
Pulmonary Function Tests
Obstruction
Non- PulmonaryOrgan Involvement
Pulmonary Involvement Only
Churg-Strauss Chest x-ray NormalIgE < 1.000
Chest x-ray Abnormal IgE > 2.000
Asthma
Allergic Bronchopulmonary Aspergillosis Bronchocentric Granulomatosis
Restriction
Bronchoalveolar Lavage
PneumocystisStrongyloidesAspergillusCryptococcus
> 20% Eosinophils < 20% Eosinophils
Blood Eosinophil Count Interstitial Lung DiseaseDrug Reaction
High Moderate Low/Normal
Hypereosinophilic Syndrome
Chronic Eosinophilic Pneumonia Simple Pulmonary Eosinophilia
Acute Eosinophilic Pneumonia
CEP ABPA CSS HIS
Subacute Acute, subacute, chronic Acute, subacute, chronic Subacute, chronic
+ (30 – 60 %) Nearly 100% 100% -
Mild – mod. In most Typical Extreme, fluctuating Extreme, persistent
Striking In some Prominent Striking
Mod. –elev. In 30% Marketed elev. , fluctuates w/disease
Mod. –elev. Mod. –elev. In some
Unknown Aspergillus (or other fungus) Unknown 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 RVD OVD +/- RVD OVD +/- RVD Mild RVD in some
None See Table 72 – 4 Histopathology plus appropriate clinical setting
Extreme persistent eosinophilia and multi-organ dysfunction (no other evident cause)
Occasionally mild, non –necrotic
None Characteristic (see text) None
Very rare reported None Typical of vasculitic phase Cardiac, neurological. GI, hematological, other
Corticosteroids Corticosteroids, bronchodilators, antibiotics, antifungals
Corticosteroids, other immunosuppressive (see text)
Corticosteroids, other immunosuppressive (see text)
Common Typical Infrequent after Rx Chronicity typical
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