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Workup of Eosinophilia in a Complex Case

Q:I have recently seen a 43 year-old woman who has had asthma since age 18 (allergic, with animal dander, dust mites as triggers), and was diagnosed with rheumatoid arthritis at age 35 after developing pleurisy. RA and asthma respectively had been treated with Humira and Advair maintenance for years. She has had an increase in respiratory symptoms since moving into her new home in the Fall of 2012, including a hospitalization for pneumonia in December 2012, presumably secondary to either Streptococcal pneumonia or fungal infection. Pneumonia symptoms took two months to resolve. During this time, she was noted to have significant eosinophilia, and has subsequently been found to have eosinophilic gastrointestinal disease (esophagitis and gastritis). Currently, her symptoms include bloating and decreased appetite, with asthma and allergic rhinitis under good control at present. She has had two other episodes of pneumonia, one at age 4 resulting in hospitalization, and another treated as an outpatient when she was in college. Additionally, sinusitis and bronchitis have occurred 2-3 times/year since her RA diagnosis.

More detailed chronologic lab evaluation to date:

2005: 2.7% eosinophils or 0.25 = wnl
2008: 0.2% eosinophils; ESR 7 wnl
2011: Eosinophil count 2600
6/2012: WBC 8 x 20% = 1600 eosinophils
10/2012 WBC 11.6 x 16% = 1856 eosinophils; ESR 7
10/2012 WBC 9.5 x 28% = 2660 eosinophils; Quantitative immunoglobulins wnl; Tetanus, Hib titers normal. Pneumococcal titers subtherapeutic in 19 of 23; Food allergies: Serum IgE + to egg white.
  10/2012 Prick skin test positive for tree pollen, grass pollen, weed pollen, dust mite, cat and dog danders; exhaled nitric oxide < 20 ppb
Eosinophils 4655 (WBC 13.3 x 35%); total IgE elevated at 425, Aspergillus fumigatus IgG 156, (all abnormally elevated). Aspergillus fumigatus IgE < 0.35 and alpha 1 antitrypsin wnl 10/2012 IgE cladosporium, Penicillium, A. niger: wnl; Eosinophils 2763; total IgE 307 ku/L; myeloperoxidase and proteinase 3 wnl Sinus CT: mild mucosal thickening maxillary sinuses > ethmoids; L osteomeatal complex occluded or stenotic. Rightward septal deviation with spur contacting inferior turbinate. CT chest without contrast: Resolution of opacities; no bronchiectasis or interstitial disease. Minimal scarring LL base and L apex
10/2012 Hep A IgM wnl; HepBsAg & HepBcAb wnl; Hep C Ab +; IgE 412 ku/L; Toxocara ab wnl; tryptase wnl; Schistosoma IgG ab wnl; Hep B RNA wnl; Ascaris IgE neg; Strongyloides IgG neg; Echinococcus IgE 18 ku/L Class 4, CT abdomen and pelvis: duodenal thickening - mild; no other pathology, questionable; Stool O&P neg x 2; normal CMP (LFTs) and rheumatoid factor negative
10/2012 EGD biopsies of gastric antrum show chronic moderate eosinophilia. Distal esophagus biopsy with Eos up to 50 /HPF. Report states no parasite and eosinophils are extending into muscularis mucosa. Was diagnosed with eosinophilic esophagitis. Also grossly evidence of candidiasis in esophagus. No H Pylori.
10/2012 Prick skin testing to food allergens was positive for milk, wheat, corn, peanut, tomato, almond, walnut, chocolate, sesame, rye, oat, pork, chicken, turkey, pineapple, green bean, carrots and cauliflower, and egg!
Summary of labs: This 43-year-old female with allergic rhinitis, allergic asthma, rheumatoid arthritis, and eosinophilia has had diagnostic studies remarkable for: eosinophilia 2600-4600 since 2011, elevated IgE 307-425 ku/L ; stool studies neg x 3 for O&P; echinococcus IgE class 4 but ruled out parasite by infectious disease; non-protective titers to pneumococcus (19/23); Positive Hep C antibody; CT abdomen with mild duodenal thickening, CT chest with basal scarring; CT sinus with mild mucosal thickening and occluded LOMC; EGD with marked chronic eosinophilic gastritis, distal eosinophilic esophagitis ~50 / hpf; food allergies.
Current meds: Alvesco 160 2 puffs qd, Singulair 10 mg qd, Omeprazole 20 mg qod (qod due to her bloating intolerance); Flovent 220 mcg 2 puffs swallowed qd, Humira, Fluconazole 100-200 mg po qd x 14 days

What workup would you recommend, and what might explain these findings?

A: This is a great case, with an excellent work up to date. This patient may have - and have had all along - idiopathic hypereosinophilic syndrome (HES). This would explain both chronic hypereosinophilia and GI eosinophils. At this point, it would be prudent to check for the FIP-1-alpha mutation, because if this positive, it would suggest that Gleevac can be used in the treatment. A bone marrow biopsy looking for clonality is perfectly justified.

The positive Hep C antibody is bothersome, and should be followed by a Hep C quantitative PCR. There is no reason for a person who has not been infected with Hep C to have a positive antibody. A truly positive Hep C may be consistent with IV drug use/other contributing factors, if you think that possible here. We had a recent case of persistent eosinophilia and recurrent pulmonary infiltrates temporally related to smoking marijuana (which may have impurities resulting in eosinophilic pneumonia and blood eosinophilia).

Regarding the positive echinococcus, this may not represent a true infection. There are reports of positive serologies to echinococcus without infection, and even other parasitic pathogens not found in the US!

 
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