Incidence of peripheral blood eosinophilia and the threshold eosinophile count for indicating hypereosinophilia-associated diseases

Prevalence and management of eosinophilia based on periodic health examinations in primary care clinics

Background

Eosinophilia is a common, hematologic abnormality detected in periodic health checkups with diverse etiologies. There are a few clinical practice guidelines for the management of eosinophilia.

Objectives

To determine the prevalence of eosinophilia among patients undergoing periodic health examinations, evaluate its management and outcomes, and identify its associated factors.

Methods

We conducted a retrospective study that included patients with eosinophilia diagnosed during the 2018 periodic health examinations at Songklanagarind Hospital.

Results

The prevalence rate of eosinophilia was 9.6% (988/10,299), and most patients (52.6%) were male with a median age of 53.0 (42.0-61.0) years. Only 174 patients (17.6%) were diagnosed and further examined to identify the cause of eosinophilia; including an examination of medical history (18.4%), physical examination (93.1%), laboratory analysis (9.2%), and consultation with internists (14.9%). Empirical anthelmintic therapy was administered in 130 patients (74.7%), and 49.2% achieved resolution. The possible causes of eosinophilia were identified in 20.7% (204/988), the most common cause being atopic disease (51.5%). Patients with moderate-to-severe eosinophilia were significantly more likely to be diagnosed, undergo further laboratory tests, and proceed with consultations with internists (adjusted OR [95% CI] = 3.52 [1.97-6.32], 17.13 [5.74-51.11], and 6.38 [1.95-20.93], respectively).

Conclusions

Eosinophilia is commonly identified in periodic health examinations, and most primary physicians lack knowledge regarding the diagnostic work-up required to determine the cause of eosinophilia. Empirical anthelmintic therapy showed satisfactory efficacy for the management of eosinophilia in areas where parasite infection is endemic.

A diagnostic score for eosinophilic granulomatosis with polyangiitis among eosinophilic disorders

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a form of systemic vasculitis with eosinophilic inflammation. However, existing classification criteria are all designed to classify EGPA among vasculitis and there is no established method distinguishing EGPA from other eosinophilic disorders. The aim of the present study was to propose a scoring system to differentiate EGPA among eosinophilic disorders.

METHODS

Non-supervised hierarchical clustering using Ward's method and principal component analysis (PCA) were performed for 19 clinical parameters of 58 patients with eosinophilia-related diseases at a tertiary university hospital. The newly proposed scoring system was externally validated in 40 patients at another tertiary institution.

RESULTS

Two distinct clusters were identified, and clinical features including peripheral neuropathy, asthma, skin involvement, lung involvement, rheumatoid factor (RF) positivity, myeloperoxidase (MPO)-anti-neutrophil cytoplasmic antibody (ANCA) positivity, IgE elevation, C-reactive protein (CRP) elevation, and vasculitis pathological findings were predominantly observed in one of these clusters (p < 0.05). Ten features defining the cluster with a high rate of vasculitis were weighted by PCA to create the E-CASE (EGPA classification among systemic eosinophilia) scoring system, on a 16-point scale. Based on the distribution of scores in the primary cohort, we defined an E-CASE score ≥12 as positive, ≤ 8 as negative, and 9-11 as undeterminable. The sensitivity and specificity of the E-CASE score in the validation cohort were 93.3% and 100%, respectively.

CONCLUSIONS

We developed and verified a novel scoring system for differentiating EGPA from other types of eosinophilic disorders.

Hypereosinophilia management in patients with type 2 chronic rhinosinusitis treated with dupilumab: preliminary results

PURPOSE

Biological therapies are gaining relevance in the management of CRSwNP with few adverse events reported. Among these, dupilumab, an anti-IL4-Ra monoclonal antibody, is frequently associated with hypereosinophilia (HE) which usually remains silent and progressively resolves, although some cases of systemic involvement occurs. The aim of this paper is to describe our experience and propose a management flowchart for HE during therapy with dupilumab.

METHODS

Patients with CRSwNP who satisfied EPOS2020 criteria for biological therapies were included in this prospective study. Each case was discussed in a multidisciplinary meeting with subsequent prescription of dupilumab; all patients were candidates to follow-up bi-monthly for 6 months, while additional blood tests were scheduled in the event of HE.

RESULTS

A total of 21 patients with a mean age of 48.4 years were enrolled. Of these, 15 of 21 presented an asthma comorbidity and 9 of 21 ASA sensitivity. Four patients (19%) developed HE with AEC > 1.5 × 10⁹/L, whereas it occurred in 9.5% (two patients) if considered AEC > 3 × 10⁹/L. No cases of hypereosinophilic syndrome were recorded. Following our decision-making flowchart, two patients received short-term corticosteroid therapy, whereas the other two were only eligible for closer follow-up.

CONCLUSIONS

During dupilumab therapy, HE may occur and should be considered benign when < 3 × 10⁹/L in the absence of organ involvement. Conversely, in case of HE ≥ 3 × 10⁹/L, an empirical approach with short-term corticosteroid therapy should be considered to debulk the blood from eosinophils and prevent potential organ involvement.

Th17 cells reflect colon submucosal pathologic changes in active eosinophilic granulomatosis with polyangiitis

BACKGROUND

Chronic eosinophilic pneumonia (CEP) or eosinophilic gastroenteritis (EG), or both, with asthma precede the onset of eosinophilic granulomatosis with polyangiitis (EGPA) in half of all EGPA patients. It is not known what determines whether patients with CEP or with EG following asthma will develop EGPA.

METHODS

We studied 17 EGPA patients and 12 patients with CEP but without EGPA. We assayed serum ICAM-1, VCAM-1, and VEGF, and the percentage of peripheral blood CD4(+) T cells producing IL-17 (Th17 cells), at both onset and remission. We also examined the numbers of submucosal eosinophils and the basement membrane-to-crypt and crypt-to-crypt distance to evaluate edema in the colon submucosa at onset and remission in EGPA and at onset in CEP.

RESULTS

Nine of 12 (75.0%) CEP patients had symptoms or endoscopic findings. Colonic submucosal eosinophil counts and edema in EGPA at onset were greater than at remission or in CEP at onset. Th17 cells (%) and serum ICAM-1 levels at onset were greater in EGPA than in CEP. In EGPA, peripheral blood Th17 cells (%) were significantly correlated with serum ICAM-1 level, colonic submucosal eosinophil count, and degree of edematous change; inversely correlated with serum VEGF level; but not correlated with VCAM-1 level.

CONCLUSIONS

Eosinophilia and colonic submucosal edematous change were greater in EGPA than in CEP. The mechanism of vasculitis in EGPA appears related to increases in serum Th17 cell numbers and ICAM-1 levels and decreases in VEGF levels.

Secondary adrenocortical insufficiency complicated by marked hypercalcemia and eosinophilia: a case report

A 56 year old female was admitted to a local hospital after developing symptoms, including generalized fatigue, nausea and vomiting, from trauma. She was relocated to our hospital because she developed other symptoms, including disturbance of consciousness from hypercalcemia and a rash over her entire body. Her clinical symptoms (disturbance of consciousness, loss of appetite, nausea, vomiting, decrease in blood pressure, fever) and examination findings (low blood cortisol levels (1.2 μg/dl ), hypercalcemia (11.0 mg/dl ), peripheral blood eosinophilia (1,600 /μl )) lead to a diagnosis of adrenal insufficiency. In addition, a skin biopsy indicated eosinophilic infiltration, although her condition improved in the end with an oral dose of 30 mg/day of prednisolone. Hypercalcemia and peripheral blood eosinophilia are commonly known examination findings for adrenocortical insufficiency, but it is rare for either of these to be present as clinical symptoms.

Characteristics and clinical outcome of patients with hypereosinophilia of undetermined significance

The term “hypereosinophilia of undetermined significance” (HE_us) previously known as idiopathic, benign eosinophilia relates to patients who have a long-lasting, unexplained and asymptomatic blood HE. These patients have not been studied so far in terms of demographic characteristics and clinical outcome. The aim of this study was to present the clinical characteristics and outcome of HE_us patients. This is a retrospective, single-center study of 40 patients with HE_us. All patients underwent the basic and specialized evaluations in order to rule out the most common causes of blood HE, but no abnormalities were detected. Twelve patients with at least moderate blood hypereosinophilia (defined as greater than 3.0 × 10⁹/L) for more than 1-year duration were treated with corticosteroids (CS) to avoid end-organ damage. Twenty-one patients (52 %) had an increased leukocyte count at diagnosis. Median blood eosinophilia was 4.2 × 10⁹/L (range 1.5–55.4). HE > 3.0 × 10⁹/L was demonstrated in 17 patients. 65 % of studied population had an increased serum IgE levels, whereas only 2 % demonstrated an increased serum vitamin B12 levels. A median bone marrow infiltration by eosinophils was 30.5 % (range 11–78.2). All treated patients responded promptly to CS and remained in complete remission while receiving low doses of CS (20 mg/day to 5 mg every 2-day). One patient developed hypereosinophilic syndrome (HES) after 11 years of follow-up. Further studies are needed to define risk factors of HES development. The use of CS for HE_us patients is controversial and should be individualized.

A case of warfarin-induced eosinophilia

Warfarin is widely used in clinical practice all over the world. We report a man in whom prominent eosinophilia appeared after the initiation of warfarin administration following aortic valve replacement. Laboratory data following the administration and discontinuation of warfarin suggested that this drug was responsible for the eosinophilia. It is important to recognize the possibility of warfarin-induced hypereosinophilia as a latent adverse effect even when there are no clinical signs or symptoms.

A case of hypereosinophilic syndrome presenting with intractable gastric ulcers

We report a rare case of hypereosinophilic syndrome (HES) presenting with intractable gastric ulcers. A 71-year-old man was admitted with epigastric pain. Initial endoscopic findings revealed multiple, active gastric ulcers in the gastric antrum. He underwent Helicobacter pylori (H pylori) eradication therapy followed by proton pump inhibitor (PPI) therapy. However, follow-up endoscopy at 4, 6, 10 and 14 mo revealed persistent multiple gastric ulcers without significant improvement. The proportion of his eosinophil count increased to 43% (total count: 7903/mm³). Abdominal-pelvic and chest computed tomography scans showed multiple small nodules in the liver and both lungs. The endoscopic biopsy specimen taken from the gastric antrum revealed prominent eosinophilic infiltration, and the liver biopsy specimen also showed eosinophilic infiltration in the portal tract and sinusoid. A bone marrow biopsy disclosed eosinophilic hyperplasia as well as increased cellularity of 70%. The patient was finally diagnosed with HES involving the stomach, liver, lung, and bone marrow. When gastric ulcers do not improve despite H pylori eradication and prolonged PPI therapy, infiltrative gastric disorders such as HES should be considered.

Hypereosinophilic syndrome in an atopic patient

Hypereosinophilic syndrome (HES) is a rare, heterogeneous group of systemic diseases characterized by sustained overproduction of eosinophils leading to variable end-organ damage. The skin is affected in 45-60% of patients and may be of diagnostic and prognostic value. In 1975, three criteria were suggested for the diagnosis of HES: (i) blood eosinophilia of > 1.5 x 10(9)/L present for > 6 months, (ii) no apparent cause for the hypereosinophilia, and (iii) signs of end-organ dysfunction. We present a patient with hypereosinophilia in whom a delay in diagnosing HES occurred, partly due to his atopic constitution. However, atopy is not associated with such high or longstanding eosinophilia.

[Hematological disorders and hypereosinophilias]

Hematological disorders are the third cause of hypereosinophilia, after allergic and parasitic diseases. Hematological disorders associated with hypereosinophilias can be classified as clonal, reactive or idiopathic, and recently the improvements of cytogenetic, molecular biology and immunology have allowed to revisit numerous cases previously diagnosed as idiopathic hypereosinophilic syndrome. Reactive eosinophilias are mainly associated with lymphoma or abnormal, often clonal T lymphoid population. Clonal eosinophilia is related either to various myeloid malignancies or to a genuine myeloproliferative disorder from the eosinophile lineage, the so-called chronic eosinophilic leukaemia. Chronic eosinophilic leukaemia can be associated with recurrent genes rearrangements involving PDGFRA, PDGFRB and FGFR1 or with clonal abnormalities not yet categorized. Idiopathic hypereosinophilic syndrome remains an exclusive diagnosis in presence of moderate or severe unexplained eosinophilia with target organ damage. The purpose of the diagnostic work-up of hypereosinophilic syndrome is to evidence either an abnormal T cell population or a clonal haematopoiesis. Imatinib mesylate dramatically improves chronic eosinophilic leukaemias associated with PDGFR abnormalities, while corticosteroids are still the main treatment for the other patients. In a near future, advances could arise from identification of new genes involved in clonal eosinophilia or in alternative therapy such as the anti-IL-5 antibodies.

Eosinophilia: A study of 100 hospitalized patients

BACKGROUND

Eosinophilia accompanies a large number of diseases and conditions, but information is lacking about the clinical characteristics of patients who are hospitalized due to this abnormality. Our aim was to determine the clinical profile and most informative diagnostic tests in patients hospitalized in a tertiary hospital because of hypereosinophilia.

METHODS

A retrospective review was done of the medical records of all patients hospitalized in a large urban medical center due to hypereosinophilia. All relevant clinical, laboratory, and imaging data were analyzed.

RESULTS

A total of 100 patients were included in the study (58 males and 42 females, mean age 55.2+/-29 years). The blood eosinophil blood count was 4107+/-7254/mul (mean+/-SD) and this usually persisted for a few months. The cause of the eosinophilia was asthma or other atopic disease in 13% of the cases, allergic drug reaction in 6%, eosinophilic pneumonia in 10%, neoplastic diseases in 10%, idiopathic hypereosinophilic syndrome in 8%, Churg-Strauss Syndrome in 4%, infections in 10%, allergic fungal disease in 2%, and skin diseases in 3%; the cause remained unknown in 34% of cases.

CONCLUSION

Guidelines are suggested for the investigation of patients with eosinophilia, including the level of the eosinophilia associated with specific diseases and the most informative diagnostic tests.

Atypical presentation of eosinophilic endomyocardial disease

Idiopathic hypereosinophllic syndrome is classically defined as prolonged, unexplained peripheral eosinophilia in a patient presenting with evidence of end-organ damage. The heart is frequently Involved, resulting In eosinophilic endomyocardial disease and eventually restrictive cardlomyopathy. The mortality rate is high because of progressive heart failure or ventricular arrhythmias. We describe a patient who presented with a left ventricular apical thrombus without notable peripheral eosinophilia. Findings from clinical evaluation and extensive diagnostic testing, including right ventricular biopsy, were Inconclusive. Resection of the thrombus and subjacent endomyocardium revealed eosinophilic Infiltration of the endomyocardium, which led to the diagnosis of eosinophilic endomyocardial disease. Clinicians should be aware of the variable presentation of patients with eosinophil-associated endomyocardial disease so that affected patients may benefit from early diagnosis and treatment.

Modern diagnosis and treatment of primary eosinophilia

The recent discovery of an eosinophilia-specific, imatinib-sensitive, karyotypically occult but fluorescence in situ hybridization-apparent molecular lesion in a subset of patients with blood eosinophilia has transformed the diagnostic as well as treatment approach to eosinophilic disorders. Primary (i.e. nonreactive) eosinophilia is considered either "clonal" or "idiopathic" based on the presence or absence, respectively, of either a molecular or bone marrow histological evidence for a myeloid neoplasm. Clonal eosinophilia might accompany a spectrum of clinicopathological entities, the minority of whom are molecularly characterized; Fip1-like-1-platelet-derived growth factor receptor alpha (FIP1L1-PDGFRA(+)) systemic mastocytosis, platelet-derived growth factor receptor beta (PDGFRB)-rearranged atypical myeloproliferative disorder, chronic myeloid leukemia, and the 8p11 syndrome that is associated with fibroblast growth factor receptor 1 (FGFR1) rearrangement. Hypereosinophilic syndrome (HES) is a subcategory of idiopathic eosinophilia and is characterized by an absolute eosinophil count of > or =1.5 x 10(9)/l for at least 6 months as well as eosinophil-mediated tissue damage. At present, a working diagnosis of primary eosinophilia mandates a bone marrow examination, karyotype analysis, and additional molecular studies in order to provide the patient with accurate prognostic information as well as select appropriate therapy. For example, the presence of either PDGFRA or PDGFRB mutations warrants the use of imatinib in clonal eosinophilia. In HES, prednisone, hydroxyurea, and interferon-alpha constitute first-line therapy, whereas imatinib, cladribine, and monoclonal antibodies to either interleukin-5 (mepolizumab) or CD52 (alemtuzumab) are considered investigational. Allogeneic transplantation offers a viable treatment option for drug-refractory cases.