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1. Dr Bikal Lamichhane
1st year resident,IM
NAMS
Approach to eosinophilia

2. INTRODUCTION
 Eosinophilia – AEC ≥500 eosinophils/microL
 Hypereosinophilia – ≥1500 eosinophils/microL (with or
without end-organ damage).
 Hypereosinophilic syndromes (HES) – AEC ≥1500/microL
(on two occasions ≥1 month apart) plus organ dysfunction
attributable to eosinophilia. HES comprise diverse clinical
syndromes

3. CAUSES OF EOSINOPHILIA

5. APPROACH
History —
 Constitutional: Fever, night sweats, unintentional weight loss, fatigue
 Cutaneous: Eczema, pruritus, urticaria, angioedema, rash, ulcers
 Cardiac: Dyspnea, chest pain, palpitations, symptoms of heart failure
 Respiratory: Nasal/sinus symptoms, wheezing, cough, chest
congestion
 Gastrointestinal: Weight loss, abdominal pain, dysphagia, nausea,
vomiting, diarrhea, food intolerance, changes in stools
 Nervous system: Transient ischemic attack, cerebrovascular accident,
behavioral changes, confusion, balance problems, memory loss, change
in vision, numbness, weakness, pain
 Other: Including symptoms attributable to lymphadenopathy or
hepatosplenomegaly (ie, new abdominal or chest discomfort, early
satiety), ocular findings, genitourinary complaints, myalgia, arthralgia,
and anaphylaxis

6.  Medications – Current and past medications should be reviewed in
detail, since eosinophilia can be caused by almost any prescription or
nonprescription drug, herbal remedy, or dietary supplement
 Dietary history should explore ingestion of raw or undercooked fish or
shellfish, meat, and vegetables as potential sources of parasitic infection
(eg, Trichinella, Toxocara, Paragonimus). Food allergies and self-
imposed dietary restrictions should also be explored.
 Other exposures – May include infectious exposures including:
- Occupation (eg, Strongyloides infection in miners, ascariasis in
slaughterhouse workers)
- Recreational activities (eg, schistosomiasis in river rafters in endemic
areas)
- Travel or residence in countries that may be associated with infectious
exposures
Family history may be informative in rare cases of familial hematologic

7. Physical examination —
 Complete skin examination and evaluation for lymphadenopathy
and hepatosplenomegaly.
 Relevant physical findings include, rash, nasal/sinus findings,
signs of cardiac and/or respiratory abnormalities,
lymphadenopathy, hepatomegaly/splenomegaly, or neurologic
findings.

8. Laboratory and diagnostic tests
 Routine laboratory tests —
 complete blood count (CBC) with differential count
 chemistry panel that includes electrolytes and liver function tests
 Blood smear —to assess eosinophil morphology and detect other
hematologic abnormalities
 Tests for selected patients —
 Cardiac troponin –in patients with AEC ≥1500/microL, cardiac
symptoms, or suggestive abnormalities on physical examination (eg,
dyspnea, fatigue, palpitations, heart murmur, cardiac dysrhythmia).
 Vitamin B12 and tryptase – in patients with AEC ≥1500/microL,
abnormal blood smear, anemia or thrombocytopenia, splenomegaly, or
symptoms consistent with systemic mastocytosis (eg, urticaria,
anaphylaxis, flushing, or abdominal symptoms)

9.  Imaging – a chest radiograph for patients with respiratory
symptoms (eg, dyspnea, cough, wheezing, rhinosinusitis).
atients with an unexplained infiltrate or AEC ≥1500/microL, we
suggest high resolution computed tomography (CT) and
pulmonary function tests.
 Infectious evaluation – is greater in patients whose travel or
residence suggests possible exposure to parasites or other
infections

10. CLINICAL SCENARIOS
 Suspected hematologic disorder — A hematologic cause should be
considered if findings from the initial evaluation do not persuasively point
toward a clear secondary cause of eosinophilia or to a characteristic
clinical syndrome (eg, eosinophilic esophagitis, episodic angioedema
with eosinophilia, eosinophilic granulomatosis with polyangiitis)
 Findings that should prompt testing for a hematologic disorder
 Absolute eosinophil count (AEC) ≥1500/microL
 Dysplastic eosinophils or leukemic blasts
 Unexplained anemia, neutropenia, polycythemia, or thrombocytopenia
 Elevated serum B12 or tryptase levels
 Lymphocytosis (≥4000/microL)
 Unexplained lymphadenopathy, splenomegaly, or constitutional
symptoms
 Resistance of eosinophilia to glucocorticoid therapy

11.  Constitutional symptoms —
 Possible causes of eosinophilia in association with constitutional
symptoms include
- Infectious, especially in the setting of appropriate travel or residency, or if
associated with gastrointestinal, respiratory, cutaneous, or other
symptoms.
- medications, especially if associated with appropriate exposure and/or
other manifestations
- Neoplastic disorders (eg, hypereosinophilic syndromes, lymphoma, solid
tumors) should be considered in patients with lymphadenopathy,
hepatomegaly, splenomegaly; anemia, thrombocytopenia
- Eosinophilic granulomatosis with polyangiitis (EGPA, formerly called
Churg-Strauss) should be considered, especially if associated with
asthma, sinusitis, dyspnea, and/or mononeuritis multiplex.
- Autoimmune syndromes or immune dysfunction associated with
eosinophilia

12.  Gastrointestinal — Eosinophilia associated with diarrhea,
abdominal pain, anorexia, or other gastrointestinal symptoms may
be due to infectious, autoimmune, or other causes.
 Respiratory —Eosinophilia with cough, dyspnea, wheezing,
chronic nasal complaints, abnormal chest X-ray or computed
tomography (CT), and/or pulmonary emboli may be associated with
diverse causes, including asthma/allergies, medications,
autoimmune illnesses, infections, EGPA, and idiopathic conditions
 Cutaneous manifestations (eg, rash, pruritus, dermographism,
erythroderma, thickening) can be seen in association with almost
any cause of eosinophilia (Eg atopy, medications, parasitic
infections, autoimmune/inflammatory conditions, HES and other
hematologic causes, primary immunodeficiencies)

13. Thank you