Asymptomatic Eosinophilia Research Articles

Asymptomatic eosinophilia in travellers: perseverance is key!

Asymptomatic eosinophilia in travellers: perseverance is key!

Concomitant Serological and Molecular Methods for Strongyloides stercoralis Screening in an Endemic Area of Spain.

Strongyloidiasis is a widespread parasitic disease that can be life-threatening in immunosuppressed people. In the Mediterranean basin, autochthonous cases coexist with imported ones. We aimed to assess the utility of different screening methods, along with the frequency of strongyloidiasis and its associated risk factors in migrants and the native population. This cross-sectional study took place from 2019 to 2022 in the area of the Vega Baja Hospital in Alicante, Spain. Screening was performed in people who were immunosuppressed, at risk of immunosuppression, with blood asymptomatic eosinophilia, and in asymptomatic people from highly endemic countries. Screening methods were serological techniques (ELISA), stool parasitological tests (fecal concentration methods and agar plate culture), and a stool molecular test (PCR). Of the 168 participants (62.5% males, 53.0% migrants, 36.3% immunosuppressed, median age 57 years), 14 (8.3%) had confirmed strongyloidiasis, where 6 were confirmed by serology, 4 by PCR, and 4 by both methods. Overall, 9% of the migrants and 7.6% of the native-born patients were infected. Elevated IgE and hemoglobin and Latin American origin were associated with strongyloidiasis diagnosis. Screening with serology alone would have missed 28.6% of cases. We conclude that strongyloidiasis prevalence is high in our population, both in native and migrant groups, and stool PCR is a useful tool to increase case detection.

Allergic adverse reactions in children following tuberculosis chemotherapy

Introduction. Tolerability of anti-TB chemotherapy in children is an urgent problem. The study is devoted to the characteristics of adverse reactions (AR) of an aller-gic type (allergic and toxic-allergic) and the factors con-tributing to their occurrence. Materials and methods. The retrospective study included 146 children aged 0 to 14 years with respiratory TB who received TB chemo-therapy, including 22 children with multidrug-resistant agent contact (MDR-TB). The spectrum of clinical and laboratory manifestations of АRs, frequency, risk factors were studied. Results. ARswith an allergic component were observed in 54 (37.0%) children, among them allergic in 32 (21.9%) and toxic-allergic in 22 (15.1%). The most common allergic reaction was asymptomatic eosinophilia (81.2%), in other cases, a combination of eosinophilia with dermatitis or only skin manifestations. A mild degree of eosinophilia prevailed, but in 3 patients it was severe (more than 20% of eosinophils in the leuk-ogram). In toxic-allergic reactions, signs of allergy were combined with an increase in liver enzymes in 59.0% of children, less often with other disorders. It was found that the early age of children, complicated course of TB, MDR-TB regimen, hyperergic skin tests do not increase the chance of developing allergic ARs. A burdened aller-gic history increases the chance of allergic АR to anti-TB drugs 2.8 times, and the presence of a primary affect in the lung 3.1 times. Temporary discontinuation or re-placement of drugs was required much more often in toxic-allergic reactions — 40.9% than in allergic ones — 18.7% (р <0.05). Allergic and toxic-allergic reactions were reversible. Conclusion. In the development of АRs to anti-TB drugs in children, the allergic factor is of sig-nificant importance. The creation of laboratory methods for diagnosing allergic reactions to anti-TB drugs would be useful

1013. Outpatient parenteral antimicrobial therapy (OPAT)-related peripheral eosinophilia as a predictor of hypersensitivity reactions.

Abstract Background The administration of outpatient parenteral antimicrobial therapy (OPAT) has significantly increased in recent decades. OPAT offers many benefits to patients and the health care system. Best practices suggest patients on OPAT require active monitoring for adverse effects of therapy. Asymptomatic eosinophilia is common finding in patients receiving OPAT and could be benign or herald allergic drug reactions. Little is known about the practice patterns of OPAT providers in their management of asymptomatic eosinophilia. This study aimed to assess the opinions and practice patterns regarding asymptomatic eosinophilia among providers managing patients on OPAT in the United States. Methods This is a cross-sectional study of data collected from a one-time, anonymous, self-administered survey to providers who care for patients receiving OPAT. The survey was posted in the discussion forums of the Infectious Diseases Society of America (IDSA) and shared via emails to twenty ID departments in the US. Data was collected from June to July 2021. Survey responses were analyzed using Python for statistical analysis. Results Sixty-five respondents completed the survey. Thirty-six percent of respondents reported that eosinophilia occurs in up to five percent of their patients, with an average time of 1-2 weeks between antibiotic exposure and the development of eosinophilia Fig (1). Sixty-nine percent of respondents reported that they do not change their laboratory monitoring frequency in patients with asymptomatic eosinophilia. Fifty-two percent of respondents would discontinue/switch antibiotics only if the patient developed complications Fig (2). The risk of subsequent hypersensitivity reaction/end-organ damage was less frequently noted, as seventy-five percent encountered it in < 10% of eosinophilia cases Fig (1). Fig. 1Reported OPAT associated eosinophilia and subsequent hypersensitivity reaction per respondents Fig. 2 Practice patterns among survey respondents to eosinophilia Conclusion Per our survey results, OPAT-related eosinophilia is common though subsequent hypersensitivity/life-threatening reactions are not. Most surveyed ID providers monitor asymptomatic eosinophilia without changing antibiotics. Further prospective studies are needed to understand the course and best practice for asymptomatic eosinophilia among patients on OPAT. Disclosures All Authors: No reported disclosures.

ASYMPTOMATIC EOSINOPHILIA WITH REACTIVE HYPERGAMMAGLOBULINEMIA

<h3>Introduction</h3> Eosinophilia is commonly reactive (secondary eosinophilia) involving polyclonal expansion of eosinophils due to infection, atopic disease, drug allergy, or autoimmune conditions. More rarely, primary eosinophilia occurs from clonal expansion of eosinophils from underlying hematologic malignancies or idiopathic hypereosinophilic syndrome. <h3>Case Description</h3> A 72 year old male who emigrated from Ghana 19 years prior was referred to allergy clinic for allergy testing for eosinophilia of at least 2 weeks (AEC 1900 eosinophils/μL) detected on routine blood work. He was asymptomatic. Physical exam was normal. Initial workup revealed improving eosinophilia (AEC 790), lymphocytosis, and hypergammaglobulinemia (IgG 2064 g/L, IgE 1894 g/L, IgA 461 g/L). SPEP showed polyclonal gammopathy. Immunophenotyping showed normal B/T cell populations. RAST testing, tryptase, Vitamin B12, HIV, HTLV, ANCA, MPO, Strongyloides Ab, and CRP were negative. Further history revealed a diarrheal illness in Ghana a few months prior. Stool O&P from his initial primary care appointment was positive for few <i>Blastocystis hominis</i>. Repeat testing 3 months later showed continued improvement of eosinophilia (AEC 670) and persistent though improving hypergammaglobulinemia. <h3>Discussion</h3> Eosinophilia may be detected in asymptomatic patients and requires a broad differential diagnosis for underlying cause. Careful history, physical examination, and directed workup is key. Travel history is particularly important in travelers and immigrants. While the pathogenicity of <i>Blastocystic hominis</i> is controversial, the patient's reported diarrheal illness without other symptoms and otherwise negative work up makes parasitic gastroenteritis with reactive hypergammaglobulinemia the most likely etiology of this patient's asymptomatic eosinophilia.

Asymptomatic Eosinophilia Induced by Systemic Colistin Therapy: A Brief Case Report

Colistin is a polymyxin group antibiotic, and colistimethate-sodium is the prodrug form of colistin and is inactive. Colistin is often the last optional drug for nosocomial infections caused by multidrug-resistant gram-negative microorganisms. We present a case of asymptomatic eosinophilia due to systemic colistin therapy. The increasing trend of absolute eosinophil counts appeared with recurrent colistin therapy and decreased when colistin was discontinued. The Naranjo Adverse Drug Reaction Probability Scale score was 7, and this score was classified as 'probable' for this case. Clinicians should consider this drug reaction in a patient with eosinophilia and avoid unnecessary laboratory tests and treatments.

Loiasis and diurnal microfilaremia: searching at the right moment.

A healthy young woman from Cameroon was addressed to the tropical medicine consultation of the University Hospitals of Geneva to investigate an asymptomatic eosinophilia of 1.22 G/l and a history of ‘eye worms’ during childhood. Direct microscopic observation found viable microfilariae, and the stained blood smear confirmed Loa loa species.

Onset of eosinophilic esophagitis during a clinical trial program of oral immunotherapy for peanut allergy

Onset of eosinophilic esophagitis during a clinical trial program of oral immunotherapy for peanut allergy

Clozapine-associated eosinophilia with multiple systemic involvement - case report and review of literature

IntroductionDue to its mood-stabilizing properties, clozapine is known for reducing symptom severity in manic episodes of treatment-resistant bipolar disorder as well as in treatment-resistant schizophrenia. However, its use may be hindered by potential adverse effects, including hematologic ones, such as non-dose-dependent eosinophilia. The mechanism of the underlying process probably involves a type-I hypersensitivity reaction, which can manifest as either transient asymptomatic eosinophilia or as eosinophilia with multiorgan dysfunction.ObjectivesWe present the case of a patient diagnosed with manic episode of schizoaffective disorder who developed eosinophilia, with severe systemic manifestations, in response to clozapine therapy. A review of literature will be conducted in order to provide further insight into the phenomenon.MethodsCase report and literature review.ResultsThe incidence of eosinophilia reported in literature ranges between 0.2% and 62%, with its appearance about three weeks after clozapine initiation. Although clozapine is an antipsychotic that normally requires frequent monitoring due to the potential side effect of agranulocytosis, we would like to place emphasis on the possible risk of eosinophilia, in connection with potential fatal complications. As described in this report, eosinophilia could long remain unrecognized due to subsequent multiorgan involvement, including lymphadenopathy, leukocytosis, lymphopenia, anemia, liver enzyme elevations, as well as pleural effusion, all of which were described in our patient.ConclusionsClozapine-associated eosinophilia may be used as an early marker of possible clozapine-induced systemic complications and it may warrant prompt discontinuation of the causing drug, as suggested by the literature.

"Eosinophilia and Neutrophilia Associated with AntiPD-1 use in Metastatic Non-Small Cell Lung Cancer – A Case Report"

The use of immunotherapy has dramatically changed the way many cancers are treated with several studies having looked at the relationship between eosinophils and immunotherapy. This case study reports nivolumab induced eosinophilia and neutrophilia with no other systemic adverse effects in a patient with metastatic non-small cell lung cancer. A 61-year-old woman with Eastern Cooperative Oncology Group performance status 1 was diagnosed with metastatic non-small cell lung cancer without any driver mutations and was commenced on nivolumab after progressing on platinum doublet therapy. She had mild eosinophilia and neutrophilia at baseline in the context of a lower respiratory tract infection which became more pronounced with the introduction of nivolumab. Nivolumab was ceased at week-26 due to significant eosinophilia and reached peak levels at week-35. She developed postural hypotension during the course of her disease and prednisolone was commenced to treat possible adrenal insufficiency from metastasis. The introduction of steroids led to the improvement in eosinophilia and neutrophilia. She had stable disease for 8 months after commencement of immunotherapy before progression of disease leading to clinical deterioration and death. Asymptomatic eosinophilia and neutrophilia is an extremely rare toxicity of immune checkpoint inhibitors. Its significance as prognostic and predictive marker needs to be researched further

EP44 Taking eosinophilia more seriously

Abstract Background Asymptomatic eosinophilia is common in migrants and travellers returning from the tropics, and helminth infection is the most common identifiable cause. Most helminth infections have a benign course, but some carry a risk of serious disease which is relevant to the rheumatologist as administration of immunosuppression can trigger severe reactions such as the potentially fatal hyper infection syndrome in strongyloidiasis. Helminth infections are of increasing relevance in an era of growing migration from endemic regions. A recent audit performed at a central London hospital in HIV outpatients found that of those patients with asymptomatic eosinophilia that were investigated, 28.6% had serological evidence of strongyloidiasis. Unexplained eosinophilia should be evaluated prior to starting immunosuppressive medications, especially in those who have lived in regions endemic for helminth infections. In 2010 the British Infection Society (BIS) published guidelines on the investigation of migrants and returning travellers with asymptomatic eosinophilia. We set out to establish how often our unit investigated unexplained eosinophilia prior to initiating immunosuppressive medication. Methods All patients attending rheumatology outpatients at our centre were screened and included if they had a recorded eosinophilia of ≥ 0.8 X109/L between December 2016 to December 2018. Patients were excluded if they did not have a sustained eosinophilia ≥0.8 X109/L &amp;gt; 1 year or if another documented diagnosis was recognised as the cause of eosinophilia. Investigation of asymptomatic eosinophilia was compared to the best practice set out in British Infection Society guideline. Results 109 patients fulfilled the inclusion criteria. 64 patients did not have a sustained eosinophilia &amp;gt; 1 year and 16 had an alternate diagnosis to explain eosinophilia and so were excluded. The remaining 29 patients were included. 13 patients were male and 16 female. 16 (55%) had a diagnosis of rheumatoid arthritis. 19 (66%) had an eosinophil count &amp;gt; 1 X109/L and 7 (24%) &amp;gt; 2 X109/L. Despite this, eosinophilia was only noted in documentation for 4 (14%) patients. Five (17%) patients had a travel history documented and 4 of them had travelled to the tropics. 3 (10%) patients were investigated for eosinophilia and only 1 (3%) was investigated fully according to the BIS guideline. 14 (48%) patients were on bDMARDs and a further 6 (21%) were on cDMARDs. Of the 14 (48%) on bDMARDS, 7 had ethnic origin in the tropics. Median eosinophil count was 1.2 x109/L. One had travel history taken. All had a negative HIV test. None of the patients on biological therapy had investigations for eosinophilia. Conclusion This study confirms the local lack of awareness of eosinophilia. Most patients with unexplained eosinophilia were not identified or investigated, even prior to administration of immunosuppressive medication. With a growing migrant population, the likelihood of serious consequences of ignoring eosinophilia are rising. Disclosures: Z. Rutter-Locher: None. J. Galloway: None. B. Menon: None. A. Goodman: None.

When is Asymptomatic Peripheral Eosinophilia Early Hypereosinophilic Syndrome?

When is Asymptomatic Peripheral Eosinophilia Early Hypereosinophilic Syndrome?

Olanzapine-associated asymptomatic eosinophilia: A case report

Olanzapine-associated asymptomatic eosinophilia: A case report

STRONGYLOIDES STERCORALIS AND CANCER

Strongyloidiasis is caused by infection with Strongyloides stercoralis. Manifestations of infection can range from asymptomatic eosinophilia in immunocompetent host to disseminated disease with septic shock in the immunocompromised host. Strongyloidiasis is endemic in tropical and subtropical regions and occurs sporadically in temperate areas. Burden of adult worms in infected humans can increase substantially via autoinfection. Among immunocompromised hosts, autoinfection can lead to hyperinfection syndrome where there is massive dissemination of filariform larvae to the lungs, liver, heart, central nervous system, and endocrine glands. Most infected patients do not experience prominent symptoms. The most common manifestations are mild waxing and waning gastro-intestinal, cutaneous, or pulmonary symptoms that persist for years; others simply have eosinophilia in the absence of symptoms.

Methotrexate exposure and risk of strongyloidiasis.

Rheumatologic disease patients receiving immunomodulating drugs such as methotrexate (MTX) have increased infection rates. Strongyloides, a global endemic intestinal parasite, can cause significant or fatal disease in immunocompromised patients. The risk of serious Strongyloides infection with MTX dosed for rheumatologic disease is unknown. We performed a systematic literature review searching EMBASE, Medline and Web of Science databases. All studies reporting humans exposed to MTX and tested for Strongyloides were reviewed. Exclusion criteria were bone marrow transplantation, intrathecal route and MTX exposure completed >1year prior to clinically apparent Strongyloides disease. After excluding duplicates, 294 articles were reviewed. Of these, 29 cases were described in 27 papers. Twenty cases (69%) had an underlying rheumatologic or dermatologic disease, the rest had a haematologic disease. Hyperinfection or dissemination was found in 59% of cases (52% low-dose MTX; 75% high-dose MTX). Death occurred in 34% of cases (19% low-dose MTX; 75% high-dose MTX, P<0.01). All eight patients on high-dose MTX received other immunosuppressants. Corticosteroids were taken in 18/21 patients on low-dose MTX. One of the three patients on MTX monotherapy had hyperinfection syndrome. None had disseminated Strongyloides. Serious Strongyloides infection can occur with low-dose MTX particularly when given with other immunosuppression. Global travel and greater awareness of rheumatologic conditions in low- to middle-income countries will increase the exposure of individuals prescribed MTX (with or without corticosteroids) to Strongyloides. Strongyloides screening and treatment should be considered for individuals receiving low-dose MTX therapy, particularly if combined with additional immunosuppression.

Hypereosinophilic syndrome manifested as eosinophilic gastroenteritis and colitis in a patient undergoing hemodialysis

BackgroundHypereosinophilic syndrome (HES) consists of a group of disorders characterized by abnormal accumulation of eosinophils in the blood or peripheral tissues, independent of known secondary causes of eosinophilia. Clinical manifestations of HES are highly variable, ranging from asymptomatic eosinophilia to severe tissue damage and end-organ failure.Case presentationWe herein present the case of a 65-year-old female with a 38-year history of hemodialysis who presented with lower leg pain, fever, skin eruption with leg edema, and diarrhea. Two months before admission, she underwent placement of a stent made of nickel and titanium for abdominal aortic stenosis. Lower leg pain occurred during hemodialysis, followed by fever, pedal edema with skin eruption, and diarrhea. Gastrointestinal endoscopy, colonoscopy, and biopsy histopathology revealed colitis with massive infiltration of eosinophils, compatible with eosinophilic gastroenteritis and colitis. The patient was treated with prednisolone at an initial dose of 40 mg daily and later reduced to 10 mg daily, after which her symptoms improved and her laboratory parameters normalized. She has not experienced a relapse after 1 year of follow-up.ConclusionsOur case of HES manifested as eosinophilic gastroenteritis and colitis and was successfully treated with corticosteroids. Clinicians should consider the differential diagnosis of HES when faced with similar cases in order to effect timely and appropriate treatment.

Asymptomatic Persistent Eosinophilia in Elderly Female

Asymptomatic Persistent Eosinophilia in Elderly Female

Strongyloidiasis Outside Endemic Areas: Long-term Parasitological and Clinical Follow-up After Ivermectin Treatment.

Strongyloides stercoralis affects 30-100 million people worldwide. The first-line therapy is ivermectin. Cure is defined as the absence of larvae by parasitological methods 1 year after treatment. To date, no longitudinal parasitological studies for longer periods of time have been conducted to confirm its cure. Here, we evaluated treatment response in long-term follow-up patients with chronic infection using parasitological and molecular methods for larvae or DNA detection. A prospective, descriptive, observational study was conducted between January 2009 and September 2015 in Buenos Aires, Argentina. Twenty-one patients with S. stercoralis diagnosis were evaluated 30, 60, and 90 days as well as 1, 2, 3, and/or 4 years after treatment by conventional methods (fresh stool, Ritchie method, agar plate culture), S. stercoralis-specific polymerase chain reaction (PCR) in stool DNA, and eosinophil values. During follow-up, larvae were detected by conventional methods in 14 of 21 patients. This parasitological reactivation was observed starting 30 days posttreatment (dpt) and then at different times since 90 dpt. Eosinophil values decreased (P = .001) 30 days after treatment, but their levels were neither associated with nor predicted these reactivations. However, S. stercoralis DNA was detected by PCR in all patients, both in their first and subsequent stool samples, thus reflecting the poor efficacy of ivermectin at eradicating parasite from host tissues. Asymptomatic eosinophilia was the most frequent clinical form among chronically infected patients. These results suggest that the parasitological cure is unlikely. Strongyloidiasis must be considered a chronic infection and ivermectin administration schedules should be reevaluated.

(A Critical Appraisal of) Classification of Hypereosinophilic Disorders.

Hypereosinophilia (HE) is a heterogeneous condition that can be reported in various (namely inflammatory, allergic, infectious, or neoplastic) diseases with distinct pathophysiological pathways. In 1975, Chusid et al. published the first diagnostic criteria of hypereosinophilic syndromes (HES). Over the years, as both basic and clinical knowledge improved, several updates have been suggested, with a focus on better distinguishing isolated or asymptomatic eosinophilia from diseases with specific eosinophil-related organ damage. Moreover, underlying molecular and cellular mechanisms of eosinophilia gradually became the cornerstone of successive attempts to classify HE-related diseases. In 2011, the International Cooperative Working Group on Eosinophil Disorders criteria emerged from a multidisciplinary Working Conference on Eosinophil Disorders and Syndromes, and provided substantial contribution to the clarification of general concepts and definitions in the field of HE. Yet, owing to the low prevalence of HE/HES, to the numerous diseases encompassed in the spectrum of HE-related disorders (with sometimes overlapping phenotypes), many questions are left unanswered (e.g., the need to better standardize the use of modern molecular tools, or the clinical relevance of distinguishing different subtypes of idiopathic HES). Here, we review the current state of knowledge in the fields of classification and diagnosis criteria of HE-related diseases, with emphasis on the analysis of both strengths and weaknesses of present concepts and their usefulness in daily practice.

Strongyloidiasis: An Incidental Discovery on Colonoscopy in an Asymptomatic Immunocompromised Host

Strongyloidiasis can range from asymptomatic eosinophilia in an immunocompetent host to disseminated disease with septic shock in an immunocompromised host. In this case, we present the incidental finding on routine colonoscopy of strongyloidiasis in an immunocompromised host. A seventy-one year-old gentleman with past medical history notable for Chronic Lymphocytic Leukemia on therapy with imatinib presented for an esophagogastroduodenoscopy (EGD) and colonoscopy for evaluation of intermittent solid food dysphagia, weight loss, and normocytic anemia. He denied any odynophagia, abdominal pain, diarrhea, constipation, hematochezia, or melena. Physical examination was normal and cursory review of the laboratory data revealed only a mild normocytic anemia. EGD was normal. Colonoscopy revealed severe pandiverticulosis and in the ascending colon, a small (< 1cm) raised sessile lesion was encountered with an odd appearance to it. It did not have the classic pattern of either a tubular or sessile serrated adenoma when examined under white light (Image 1) or narrow band imaging (Image 2). The lesion did not evert when poked by the biopsy forceps, making an inverted diverticulum unlikely. Snare cautery polypectomy was performed and later to our surprise, the pathology returned back as it being an eosinophilic abscess with numerous strongyloides organisms present (Image 3) Upon further review of the patient's chart, it was noted that he had peripheral eosinophilia for years but this had gone largely unnoticed. The patient received anti-helminthic therapy with ivermectin and did well with complete resolution of his peripheral eosinophilia over time. The most common manifestations of strongyloidiasis are mild waxing and waning gastrointestinal (i.e. diarrhea), cutaneous (i.e. rash, pruritus), or pulmonary symptoms (i.e. cough, dyspnea) that can persist for years. More often than not, patients are asymptomatic and the presence of peripheral eosinophilia is the only marker to suggest a parasitic infection. In addition, as in our case, there are no classic endoscopic features of strongyloidiasis and it can mimic that of other diseases. Overall the prognosis of strongyloidiasis is good if detected early and treated appropriately. It is especially important to be worried about infection in immunocompromised individuals given they are at risk for developing a potentially fatal hyperinfection syndrome that can result in multi-organ failure and death.Figure: Image 1- White Light View of Lesion.Figure: Image 1- Narrow Band Imaging View of Lesion.Figure: Image 3- Strongyloides filariform larvae seen in upper left portion of slide with surrounding eosinophilia.