Polyneuropathy in hypereosinophilic syndrome

Distinct features of hypereosinophilic syndrome with neuropathy from eosinophilic granulomatosis with polyangiitis

BACKGROUND AND OBJECTIVES

Hypereosinophilic syndrome (HES) and eosinophilic granulomatosis with polyangiitis (EGPA) have overlapping clinical considerations, which frequently involve peripheral neuropathy. The current study aimed to discriminate between the clinicopathological features of HES and EGPA, focusing on the mechanism of peripheral nerve damage.

METHODS

A total of 53 patients who underwent nerve biopsies at our laboratory were examined: nine patients with idiopathic HES (iHES), three patients with reactive HES, 14 patients with myeloperoxidase-anti-neutrophil cytoplasmic antibody (ANCA)-positive EGPA, and 27 patients with negative EGPA. Nerve biopsies were performed using light and electron microscopy.

RESULTS

Polyneuropathy was more common than mononeuritis multiplex in iHES, which differed from that in ANCA-negative EGPA groups (p = 0.012). Nerve biopsies showed that iHES was associated with neuropathy features such as rare vasculitis and non-vasculitic eosinophilic infiltrates, which differed from those of ANCA-negative EGPA. Fibrinoid necrosis was found only in the reactive HES and ANCA-positive groups. The percentage of endoneurial vessels occluded with eosinophils tended to be higher in iHES (1.8%) than in ANCA-positive EGPA (0%) and negative EGPA (0.7%). In a patient with ANCA-negative EGPA, the endoneurial vessels were occluded with platelets, fibrinoid materials, and eosinophils, demonstrating the morphology of eosinophil extracellular traps.

CONCLUSION

iHES with neuropathy showed a pattern more similar to polyneuropathy than mononeuritis multiplex, which is dominant in ANCA-negative EGPA, and tended to show vasculitis in the peripheral nerves less frequently compared with EGPA. Eosinophilic infiltration and endoneurial vascular occlusion by eosinophils may cause nerve damage.

Optic Neuritis Associated with Myelodysplastic Syndrome Accompanied by Eosinophilic Crisis

Myelodysplastic syndrome (MDS) was diagnosed in a 64-year-old man. Three months later, he presented with right-sided visual loss. A diagnosis of optic neuritis caused by both ischemic and non-ischemic changes was established. Concurrently, prominent eosinophilia was seen in both the peripheral blood and bone marrow. A partial improvement of visual loss was obtained concomitant with a rapid decrease of the eosinophils after treatment with corticosteroids. Optic neuritis related to MDS is a rare condition and its etiology has not yet been identified. We herein report a case of optic neuritis associated with MDS and accompanied by an eosinophilic crisis.

Clinical overview of cutaneous features in hypereosinophilic syndrome

The hypereosinophilic syndromes (HES) are a heterogeneous group of disorders defined as persistent and marked blood eosinophilia of unknown origin with systemic organ involvement. HES is a potentially severe multisystem disease associated with considerable morbidity. Skin involvement and cutaneous findings frequently can be seen in those patients. Skin symptoms consist of angioedema; unusual urticarial lesions; and eczematous, therapy-resistant, pruriginous papules and nodules. They may be the only obvious clinical symptoms. Cutaneous features can give an important hint to the diagnosis of this rare and often severe illness. Based on advances in molecular and genetic diagnostic techniques and on increasing experience with characteristic clinical features and prognostic markers, therapy has changed radically. Current therapies include corticosteroids, hydroxyurea, interferon-α, the tyrosine kinase inhibitor imatinib mesylate, and (in progress) the monoclonal anti-interleukin-5 antibodies. This article provides an overview of current concepts of disease classification, different skin findings, and therapy for HES.

[Multiple cerebral infarctions in a patient with Churg-Strauss syndrome: A case report]

We report the case of a 65-year-old woman who presented with Churg-Strauss syndrome (CSS) associated with multiple cerebral infarcts. Four years ago, she was diagnosed as having CSS based on asthma, hypereosinophilia and peripheral neuropathy, and corticosteroid therapy achieved a remission. However, she showed exacerbation of asthma and hypereosinophilia during the tapering schedule of steroid, and she was hospitalized because of dizziness and mild left side weakness. Analysis of blood chemistry detected significant hypereosinophilia (13,730/μl), increased blood-coagulating activity, elevated NT-proBNP concentration and renal dysfunction. MRI of the brain revealed multiple small infarcts in cortex and the watershed area. The patient was diagnosed with exacerbation of CSS, and treatment with increased dose of corticosteroid induced a clear improvement in symptoms, with decrease of the eosinophilia and a clear improvement of the renal function. The hypercoagulable state and direct eosinophil toxicity may contribute to strokes in hypereosinophilic condition of CSS. This case was remarkable for illustrating multiple cerebral infarctions in CSS. CSS should always be considered in patients with hypereosinophilia and stroke.

Acute Myocardial Injury in a 45-year-old Female: Hypereosinophilic Syndrome

Hypereosinophilic syndrome (HES) can cause eosinophilic infiltration in multiple organ systems resulting in organ damage. Among all, cardiac involvement is the major cause of morbidity and mortality. Early diagnosis and prompt treatment are important to improve the prognosis. We reported a 45-year-old woman with a history of eosinophilia presented with chest pain in our emergency department. Laboratory tests revealed marked eosinophilia and elevated cardiac markers. A neurological event, presenting as right-side limb weakness, supervened later. The diagnosis of HES was established, and prompt treatment with corticosteroids, hydroxyurea, and imatinib resolved the eosinophilia; further cardiac and neurological injury was thus prevented. This case reminds us to consider and, if applicable, to provide the appropriate management for HES in the context of making a differential diagnosis in clinical situations involving organ damage.

Psychiatric symptoms in a patient with Churg-Strauss syndrome

We report a case of Churg-Strauss syndrome (CSS) in a patient with multiple cerebral infarctions and psychotic symptoms. A 67-year-old man presented a high-grade fever and delirium. He was clinically diagnosed with Churg-Strauss syndrome on the basis of the presence of asthma, neuropathy, blood eosinophilia, and increased myeloperoxidase-specific anti-neutrophil cytoplasmic antibody (MPO-ANCA) activities. Though multiple cerebral infarctions are irreversible, this patient's psychiatric symptoms improved with steroid treatment. Psychiatric symptoms associated with CSS are very rare.

Clinical overview of hypereosinophilic syndromes

Hypereosinophilic syndrome (HES) or syndromes are disorders characterized by chronic peripheral blood hypereosinophilia with damage to various organs due toeosinophilic infiltration and release of mediators. HES is most accurately described as a collection of heterogeneous disorders, with some similarities in clinical features, but many differences. Based on recent advances in molecular and genetic diagnostic techniques and increasing experience with differences in clinical features and prognosis, some subtypes of HES have been defined, such as myeloproliferative variants, including chronic eosinophilic leukemia, and lymphocytic variants, but other subtypes remain undefined. Recent evidence suggests that, in addition to differences in clinical features, the range of complications, treatment options, and prognoses differs significantly among the myeloproliferative, lymphocytic, and undefined variants of HES.

Recurrent Optic Neuritis as the Presenting Manifestation of Primary Hypereosinophilic Syndrome: A Report of Two Cases

Two patients sustained multiple attacks of optic neuritis with persistent visual loss. An elevated eosinophil count was initially considered an incidental finding. Years later, the diagnosis of primary hypereosinophilic syndrome (HES) was confirmed by skin and bone marrow in one patient and by lung biopsy in the other. Treatment with hydroxyurea in one patient and with continuous low-dose prednisone in the other stopped the optic neuritis attacks, resolved systemic manifestations, and stabilized neurologic manifestations. These cases emphasize that primary HES may be a cause of recurrent optic neuritis, and that delay in diagnosis and treatment of primary HES can lead to visual morbidity.

Clinicopathological features of Churg-Strauss syndrome-associated neuropathy

We assessed the clinicopathological features of 28 patients with peripheral neuropathy associated with Churg-Strauss syndrome. Initial symptoms attributable to neuropathy were acute painful dysaesthesiae and oedema in the dysaesthetic portion of the distal limbs. Sensory and motor involvement mostly showed a pattern of mononeuritis multiplex in the initial phase, progressing into asymmetrical polyneuropathy, restricted to the limbs. Parallel loss of myelinated and unmyelinated fibres due to axonal degeneration was evident as decreased or absent amplitudes of sensory nerve action potentials and compound muscle action potentials, indicating acute massive axonal loss. Epineurial necrotizing vasculitis was seen in 54% of cases; infiltrates consisted mainly of CD8-positive suppressor/cytotoxic and CD4-positive helper T lymphocytes. Eosinophils were present in infiltrates, but in smaller numbers than lymphocytes. CD20-positive B lymphocytes were seen only occasionally. Deposits of IgG, C3d, IgE and major basic protein were scarce. The mean follow-up period was 4.2 years, with a range of 8 months to 10 years. Fatal outcome was seen only in a single patient, indicating a good survival rate. The patients who responded well to the initial corticosteroid therapy within 4 weeks regained self-controlled functional status in longterm follow-up (modified Rankin score was < or = 2), while those not responding well to the initial corticosteroid therapy led a dependent existence (P < 0.01). In addition the patients with poor functional outcomes had significantly more systemic organ damage caused by vasculitis (P < 0.05). Necrotizing vasculitis mediated by cytotoxic T cells, leading to ischaemic changes, appears to be a major cause of Churg-Strauss syndrome-associated neuropathy. The initial clinical course and the extent of systemic vasculitic lesions may influence the long-term functional prognosis.

[Non-infectious inflammatory fasciitis: a borderline syndrome]

Inflammatory fasciitis without infection include different entity like eosinophilic fasciitis, the syndrome of eosinophilia-myalgia after tryptophan ingestion, toxic oil syndrome, exposure to trichlorethylene, phenylketonuria skin changes, the syndrome of palmar fasciitis, fasciitis in chronic graft-versus-host disease and fasciitis secondary to an adjacence process. The diagnosis of all these scleroderma-like skin changes is sometimes not easy because the clinical and sometimes the histopathological changes are bordeline manifestations with scleroderma. The most characteristic markers for non infectious fasciitis is eosinophilia and the infiltration of the fascia with eosinophilis, but it may be unremarkable or absent, only frequently present at the onset of the disease. Anamnesis is most important to guide the diagnosis. The eosinophils, but not only, may play a major role in the pathogenesis of this entity.

Two cases of neurological manifestations in eosinophilia: variations of one disease?

The hypereosinophilic syndrome is characterized by a long-lasting increase in circulating eosinophils in the absence of a definable etiology and by manifestations of multisystem involvement. It must be differentiated from the eosinophilia-myalgia syndrome related to the ingestion of L-tryptophan, although the clinical features may be similar. Two patients with hypereosinophilia not related to L-tryptophan intake are described who both became clinically symptomatic with neurological manifestations of acute and subacute onset: one with eosinophilic fasciitis and the other with painful polyneuropathy. Both responded well to corticosteroids.

Neurotoxicity of idiopathic hypereosinophilia on a case with simultaneous CNS and PNS involvement

We report the case of a patient with idiopathic hypereosinophilia in whom both central and peripheral nervous systems were affected. We discuss possible pathogenetic mechanisms explaining the neurotoxicity of idiopathic hypereosinophilia. Corticosteroid therapy should be given early and continued indefinitely.

Peripheral nerve involvement in Churg-Strauss syndrome

Peripheral neuropathy associated with bronchial asthma, multisystem organ dysfunction and idiopathic hypereosinophilia may be found in Churg-Strauss syndrome, hypereosinophilic syndrome and polyarteritis nodosa. Some authors have diagnosed their patients according to the presence in tissue biopsies of the three histological criteria of Churg and Strauss (necrotizing vasculitis, tissue eosinophilic infiltration, extravascular granulomas). We have observed three patients with a common history of a prodromal phase of allergic diseases (bronchial asthma and rhinitis) followed by a vasculitic phase with mononeuritis multiplex, purpura and arthritis, associated with hypereosinophilia of more than 1500 cells/mm3. All responded well to steroid treatment. Sural nerve biopsy revealed true vasculitis in two of these cases and a mild perivascular inflammatory infiltration in the other. On the basis of their characteristic clinical pattern, we think that our cases best fit the diagnosis of Churg-Strauss syndrome even though the typical histological features were not found in the sural nerves examined.

Demyelinating polyneuropathy in eosinophilia-myalgia syndrome

Eosinophilia-myalgia syndrome (EMS) is a newly recognized disorder, characterized by myalgia, weakness, scleroderma-like changes, and eosinophilia. EMS is associated with lots of L-tryptophan allegedly contaminated with byproducts of the manufacturing process. We describe 3 patients with EMS who presented with a severe demyelinating sensorimotor polyneuropathy. Electrodiagnostic studies revealed multifocal conduction block, slowing and temporal dispersion of motor responses, and prolonged or absent F-responses. Despite plasmapheresis; corticosteroids; and, in 1 patient, cyclophosphamide, 2 patients died and the remaining patient experienced minimal recovery. Pathology revealed patchy perivascular infiltrates and fibrosis in the connective tissue of muscle and nerve. Autopsy of the central nervous system in 2 patients did not reveal changes unique to EMS. In addition to other organ involvement, EMS may manifest as a potentially fatal polyneuropathy, which initially appears to have prominent demyelinating features.

Multifocal peripheral neuropathy in eosinophilic fasciitis

Polyneuropathy may complicate eosinophilia-associated connective tissue disease. We report a multi-focal neuropathy in a patient with eosinophilic fasciitis proven by demonstrating an eosinophilic cellular infiltrate in a fascial biopsy specimen from the forearm. Sural nerve biopsy revealed lymphocytic cuffing of epineural arterioles. Although described in the L-tryptophan-related eosinophilia-myalgia syndrome, peripheral neuropathy with these features has not been previously noted in a patient with eosinophilic fasciitis who had not consumed L-tryptophan.

Peripheral neuropathy in hypereosinophilic syndrome with vasculitis

A 53-year-old woman with non-productive cough of unexplained aetiology for two years, developed a sub-acute symmetrical polyneuropathy involving all four limbs, accompanied by fever, cutaneous rash and myalgia in lower limbs. Laboratory studies revealed a leukocytosis with 70% eosinophils and excluded any cause for the hypereosinophilia. An echocardiogram showed increase in thickness of the atrial septum. Motor and sensory conduction velocity were reduced in ulnar and median nerve and unrecordable in peroneal and tibial nerves. A sural nerve biopsy showed an axonal degeneration involving myelinated and unmyelinated fibers as well as a vasculitis with fibrinoid necrosis and perivascular infiltration of eosinophils. There was considerable clinical and laboratory improvement with the use of steroids. The differential diagnosis between idiopathic hypereosinophilic syndrome and other disorders known to course with vasculitis and hypereosinophilia is discussed.

[Peripheral neuropathy and idiopathic hypereosinophilic syndrome: review of the literature apropos of a case with atypical presentation]

Involvement of the nervous system in the idiopathic hypereosinophilic syndrome is a common finding, peripheral neuropathy being the most frequent neurologic manifestation, usually appearing at the onset or following the appearance of eosinophilia. We describe here the case of a 42 year-old male patient with persistent eosinophilia (greater than 1500/mm3) for a period greater than six months in the absence of a known cause for the eosinophilia with end-organ injury, in whom the neurologic involvement preceded by months the elevation of peripheral blood eosinophil count, and consisted of peripheral neuropathy and the unusual involvement of a cranial nerve. There was severe distal wasting and weakness of the four limbs with sensory abnormalities which developed over a period of four months, along with left-sided deafness which was due to eighth cranial nerve involvement. Electrodiagnostic studies showed generalized nerve involvement of the axonal type. Nerve biopsy did not reveal eosinophilic infiltration or vasculitic changes, suggesting that neurotoxic eosinophil products may play a role in the neuropathy. There was marked improvement of the eosinophilia and slight improvement of the sensorimotor disturbance in the course of corticosteroid therapy.

State of the art; the hypereosinophilic syndromes

Many disease states such as parasitic infestations, malignancies, collagen vascular diseases, and allergies are associated with eosinophilia. The diagnosis of idiopathic hypereosinophilic syndrome (HES) requires a persistent elevation in the total eosinophil count (greater than 1500/mm3) for over 6 months, associated organ damage and no detectable underlying cause. This review provides an updated summary of the cytokine cascade that controls eosinophil production and delineates our current understanding of the clinical features of hypereosinophilic states. We also examine the central role of T-lymphocyte activation in eosinophilia, and have attempted to integrate current treatment strategies for HES with the physiology of eosinophilopoiesis.

AAEM minimonograph #34: polyneuropathy: classification by nerve conduction studies and electromyography

Electrodiagnostic evaluation of patients with suspected polyneuropathy is useful for detecting and documenting peripheral abnormalities, identifying the predominant pathophysiology, and determining the prognosis for certain disorders. The electrodiagnostic classification of polyneuropathy is associated with morphologic correlates and is based upon determining involvement of sensory and motor fibers and distinguishing between predominantly axon loss and demyelinating lesions. Accurate electrodiagnostic classification leads to a more focused and expedient identification of the etiology of polyneuropathy in clinical situations.