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An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
An Unusual Cause Of Eosinophilia
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An Unusual Cause Of Eosinophilia

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  • 1. An Unusual Cause Of Eosinophilia? Or much ado about nothing?
  • 2. The mysterious case of Mrs H’s Malaise………
    • 69 Year old lady presented with chest pain ? Acute coronary syndrome.
    • She had a past medical history of asthma and high cholesterol.
    • incidentally gave a 5/12 history of general malaise, “sickliness” & weight loss.
    • MI screen negative, WCC normal, eosinophils of 4.9 (32%), Na 2+ 132.
    • CXR revealed apical fibrosis ~ ? tuberculosis
    • Treated as TB with Rifinah, Ethambucol, Pyrazinamide & Isoniazid and discharged with follow up ~ awaiting AAFB results
  • 3. The Mysterious case of Mrs H’s Malaise……
    • Readmitted 8/7 later, with worsening nausea and vomiting. Thought to be dehydrated & BP low
    • Eosinophils 1.7, Na 2+ 124.
    • Given iv fluids and symptomatically improved, then Na 2+ results seen
    • Bendrofluazide stopped, fluid restricted and given antiemetics.
    • Initially pyrazinamide stopped as most likely cause of nausea & vomiting.
    • Fluid restriction stopped to allow for formal plasma/urinary osmolality & electrolytes to be sent.
  • 4. The mysterious case of Mrs H’s malaise…..
    • Plasma Osmolality 263
    • Urine Osmolality 165
    • Not SIADH ~ however Na 2+
    • continues to drop & trough’s
    • at 117.
    Mrs H was again fluid restricted despite previous results. Rpt osmolalities:Plasma 231, Urine 160, urinary Na 2+ <10. Definitely not SIADH!! No peripheral oedema Only other drugs aspirin, ramipril, atorvastatin TFTs & random cortisol normal Autoimmune screen negative AAFBs x 3 negative IgG 12.6 IgM 1.1 IgA 1.51 IgE 672
  • 5. The Mysterious Case Of Mrs H’s Malaise…..
    • On closer questioning, Mrs H believed that her non-specific symptoms could be linked to the time that her GP commenced atorvastatin.
    • All medicines were stopped except her inhalers.
    • Her symptoms then gradually improved so that she felt well enough to go home 21/7 after her re-admission.
    • On discharge Na 2+ was 133, Eosinophils 2.4.
    .
    • CXR reviewed ~ appearances significantly better so unlikely to be TB.
    • She was rehydrated and treated with antiemetics
  • 6. The Mysterious Case Of Mrs H’s Malaise……
    • We postulated that her symptoms are down to medicine SE’s ~ likely atorvastatin. Our aim was to rechallenge if her eosinophils returned to normal.
    CSM reports 1 case of pulmonary eosinophilia with atorvastatin, 1 case of peripheral eosinophilia with ramipril & 3 of hyponatraemia with ramipril.
  • 7. Pulmonary Eosinophilia
  • 8. Pulmonary Eosinophilia
    • Range from the very mild simple pulmonary eosinophilias to the often fatal polyarteritis nodosa.
  • 9. Poor/ Fair Months/years always >20% Severe Polyarteritis Nodosa Poor Months/years Always >20% Severe Hypereosinophilic syndrome Fair Years None >20% Moderate/ Severe Tropical Pulmonary Eosinophilia Fair Years None 5-20% Moderate/ Severe Asthmatic Bronchopulmonary Eosinophilia Good >1/12 None >20% Mild/ Moderate Prolonged Pulmonary Eosinophilia Good <1/12 None 10% Mild Simple Pulmonary Eosinophilia Outcome Duration Multi-system involve-ment Blood Eosino-phils% Symptoms Disease
  • 10. Simple versus Prolonged Pulmonary Eosinophilia
    • Simple Pulmonary Eosinophilia
    • Mild illness
    • Fever & cough lasting less than 2 weeks
    • Probably due to a transient allergic reaction in the alveolus
    • Self limiting
    • Prolonged Pulmonary Eosinophilia
    • Similar to simple but lasting more than a month
    • High fever
    • Peripheral eosinophilia
    • Localised or diffuse CXR opacities
    • Resolves with steroids.
  • 11. Asthmatic Bronchopulmonary Eosinophilia
      • Characterised by asthma, transient CXR shadows and blood or sputum eosinophilia.
      • Most common cause is allergy to aspergillus fumigatus.
      • Aspergillus actually grows in the wall of the bronchi and eventually produces proximal bronchiectasis.
      • Episodes of wheeze,cough,fever and malaise.
      • Association with expectoration of sputum plugs leading to clearing of CXR appearances.
      • Extremely high IgE & +ve aspergillus precipitans
      • Treatment with 30mg prednisolone ~ may need 15mg for maintenance
      • Untreated can result in progressive fibrosis that may mimic TB on CXR.
  • 12.
    • Polyarteritis Nodosa
    • Characterised by foci of necrotizing arteritis
    • Affects most organs.
    • Lung involvement unusual except in Churg-Strauss syndrome.
    • CXR may show ill-defined shadows that disappear & reappear over weeks.
    • 5 yr survival is 80% with steroid and immunosuppression
    • Churg-Strauss Syndrome .
    • Occurs in the fourth decade
    • Eosinophilic infiltration in individuals with previous history of rhinitis and asthma.
    • High eosinophils, vasculitis of small vessels and extra vascular granulomas.
    • Renal failure less likely than in PAN.
    • pANCA can be positive.
    • Responds to steroids.
  • 13. Drug induced Eosinophilia
    • Eosinophilia has been reported as a side effect of many drugs including:
    • NSAID’s
    • ACEI’s
    • Statins (peripheral)
    • Penicillins, Tetracyclines, Sulphonamides
    • Phenytoin, Carbamazepine
    • Chlorpropamide.
    • Potential drug SE’s are under reported since there is often little hard evidence
    • ? Not much known about a mechanism of eosinophilia. May precipitate a reaction in a susceptible individual.
  • 14. Conclusion….
    • Mrs H’s symptoms resolved when all meds were stopped.
    • At follow up she was well.
    • Na 2+ was 135, but eosinophils remained elevated at 3.1
    • After much excitement about possible drug causes, she was treated with steroids and made a good recovery!
    • NB: aspergillus precipitans were never measured
  • 15. Hyponatraemia & SIADH
    • ADH causes water retention
    • In hypovolaemia the action of aldosterone causes sodium retention & therefore urine Na is low
    • In SIADH only water is retained so urine Na remains inapproriately high
    • No diuretics
    • Normal adrenal & thyroid function
    • No hypotension (or low K+)
    • Low plasma osmolality with inappropriately high urine osmolality & sodium
  • 16. Hyponatraemia & SIADH
    • In this case the patient had lost salt and water in vomit and via diuretics
    • She would have tried to replace volume with water, but continued to take bendrofluazide hence ongoing salt & water loss
    • Her ACEI would interfere with the action of angiotensin 2 on the adrenals, further reducing her ability to salt conserve
    • At this sodium level treatment is simply replacing volume with saline & stopping diuretics
    • ACEI should be stopped in the short term when a patient is hypovolaemic
    • Bendrofluazide has been implicated in a few more dramatic recent cases of hyponatraemia which Dr Jones would love to tell you all about!

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