Loffler Syndrome Workup
- Author: Girish D Sharma, MD, FCCP, FAAP; Chief Editor: Michael R Bye, MD more...
The following studies are indicated in Löffler syndrome:
- CBC count with differential
- Results show mild blood eosinophilia, usually 5-20%.
- Eosinophils may account for as much as 40% of the WBC differential in patients with drug-induced eosinophilia.
- Stool examination
- Parasites and ova can be found in the stool 6-12 weeks after the initial parasitic infection.
- Pulmonary symptoms usually resolve by the time parasitic forms are found in the stool.
- Immunoglobulin E (IgE) level: This may be elevated.
- Analysis of sputum or gastric lavages: Larvae are occasionally found in sputum and gastric aspirates at the time of pulmonary symptoms.
- Bronchoalveolar lavage: The eosinophilic count may be elevated.
See the list below:
- Chest radiographyInitial chest radiograph of a 54-year-old man showing subtle opacity (arrows) in the right middle lung zone.Follow-up chest radiograph of a 54-year-old man showing migrating opacity in the left lower lobe (arrows) obtained 20 days after the previous image.See the list below:
- Roentgenographic abnormalities can be unilateral or bilateral.
- Most patients have peripheral densities, usually of a combined interstitial and alveolar pattern and often a few centimeters in diameter, although they may coalesce into larger areas of consolidation.
- Densities are generally transient, migratory, and disappear completely within 2-4 weeks.
- In drug-induced pulmonary eosinophilia, radiographic abnormalities resolve completely several weeks after withdrawal of the offending drug.
- Pleural effusions may be present in patients with nitrofurantoin toxicity. A case of eosinophilic pleural effusion with peripheral blood eosinophilia has been described with valproic acid administration.
- Chest CT scanning: One report describes areas of ground-glass opacity (halo) around consolidation or nodules observed on high-resolution chest CT scanning. See the image below.
See the list below:
- Bronchoscopy and bronchoalveolar lavage
- These procedures are rarely indicated.
- In one report, the total number of cells found in bronchoalveolar lavage fluid (BALF) from patients with drug-induced pulmonary eosinophilia was significantly elevated compared to healthy subjects. Specifically, the number of lymphocytes and eosinophils in BALF was higher than in healthy subjects. These findings were not specific for drug-induced pulmonary eosinophilia because similar numbers were found in patients with chronic eosinophilic pneumonia. In addition to elevated eosinophils and lymphocytes in BALF, patients with acute eosinophilic pneumonia had high numbers of neutrophils in BALF.
See the list below:
- Pathologic changes in the lungs have been described in patients who died from another cause while they concomitantly had simple pulmonary eosinophilia.
- Eosinophilic infiltration occurs in the bronchi and bronchioles and in the alveolar and interstitial spaces. Parasitic forms are usually not found in the lungs.
Kunst H, Mack D, Kon OM, et. al. Parasitic infections of the lung: a guide for the respiratory physician. Thorax. 2011. 66:528-36.
Plotz SG, Huttig B, Aigner B. et al. Clinical overview of cutaneous features in hypereosinophilic syndrome. Current Allergy Asthma Report. 2012. 12:85-98.
Shinde A, Seifi A, DelRe S, et al. Daptomycin-induced pulmonary infiltrates with eosinophilia. J Infect. Feb 2009. 58(2):173-4. [Medline].
Janz DR, O'Neal HR Jr, Ely EW. Acute eosinophilic pneumonia: A case report and review of the literature. Crit Care Med. 2009 Apr. 37(4):1470-4. [Medline].
[Guideline] Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of respiratory illness in children and adults. 2008 Jan. [Full Text].
Sen T, Ponde CK, Udwadia ZF. Hypereosinophilic syndrome with isolated Loeffler's endocarditis: complete resolution with corticosteroids. J Postgrad Med. 2008 Apr-Jun. 54(2):135-7. [Medline].
Abdul-Hadi S, Diaz-Bello Z, Zavala-Jaspe R, et al. Pulmonary paragonimiasis. Case report. Invest Clin. Jun 2008. 49(2):257-64. [Medline].
Alberts WM. Eosinophilic interstitial lung disease. Curr Opin Pulm Med. 2004 Sep. 10(5):419-24. [Medline].
Allen JN, Davis WB. Eosinophilic lung diseases. Am J Respir Crit Care Med. 1994 Nov. 150(5 Pt 1):1423-38. [Medline].
Carroll JL, Sterni LM. Eosinophilic lung disorders and hypersensitivity pneumonitis. Taussig LM, Landau LI, eds. Pediatric Respiratory Medicine. St Louis, Mo: Mosby; 1999. 804-10.
Corrin B. The lungs. Systemic Pathology. 3rd ed. London, England: Churchill Livinstone; 1990. 191.
Cottin V, Cordier JF. Eosinophilic pneumonias. Allergy. 2005 Jul. 60(7):841-57. [Medline].
Crofton JW, Livingstone JL, Oswald NC, Roberts AT. Pulmonary eosinophilia. Thorax. 1952 Mar. 7(1):1-35. [Medline].
Das AM, Williams TJ, Lobb R, Nourshargh S. Lung eosinophilia is dependent on IL-5 and the adhesion molecules CD18 and VLA-4, in a guinea-pig model. Immunology. 1995 Jan. 84(1):41-6. [Medline].
Fujimura M, Yasui M, Shinagawa S, et al. Bronchoalveolar lavage cell findings in three types of eosinophilic pneumonia: acute, chronic and drug-induced eosinophilic pneumonia. Respir Med. 1998 May. 92(5):743-9. [Medline].
Katz U, Shoenfeld Y. Pulmonary eosinophilia. Clin Rev Allergy Immunol. Jun 2008. 34(3):367-71. [Medline].
Kaufman J, O'Shaughnessy IM. Eosinophilic pleural effusion associated with valproic acid administration. South Med J. 1995 Aug. 88(8):881-2. [Medline].
Kim Y, Lee KS, Choi DC, et al. The spectrum of eosinophilic lung disease: radiologic findings. J Comput Assist Tomogr. 1997 Nov-Dec. 21(6):920-30. [Medline].
Lee HK, Jin SL, Lee HP, et al. Loffler's syndrome associated with Clonorchis sinensis infestation. Korean J Intern Med. 2003 Dec. 18(4):255-9. [Medline].
Ler WZ. Differential-diagnose der lungen infiltrierungen: er fle succedan-infiltrate (mit eosinophilia). Beitr Klin Tuberk. 1932. 79:368-92.
Nadeem S, Nasir N, Israel RH. Loffler's syndrome secondary to crack cocaine. Chest. 1994 May. 105(5):1599-600. [Medline].
Neva FA, Brown HW. Intestinal nematodes. Basic Clinical Parasitology. 6th ed. Norwalk, Conn: Appleton & Lange; 1994. 113-51.
Nogami M, Suko M, Okudaira H, et al. Experimental pulmonary eosinophilia in mice by Ascaris suum extract. Am Rev Respir Dis. 1990 May. 141(5 Pt 1):1289-95. [Medline].
O'Sullivan BP, Nimkin K, Gang DL. A fifteen-year-old boy with eosinophilia and pulmonary infiltrates. J Pediatr. 1993 Oct. 123(4):660-6. [Medline].
Ohnishi H, Abe M, Yokoyama A, et al. Clarithromycin-induced eosinophilic pneumonia. Intern Med. 2004 Mar. 43(3):231-5. [Medline].
Pawlowski ZS. Ascariasis. Warren KS, Mahmoud AAF, eds. Tropical and Geographical Medicine. 2nd ed. New York, NY: McGraw-Hill; 1990. 369.
Sharma OP, Bethlem EP. The pulmonary infiltration with eosinophilia syndrome. Curr Opin Pulm Med. 1996 Sep. 2(5):380-9. [Medline].
Takafuji S, Nakagawa T. Drug-induced pulmonary disorders. Intern Med. 2004 Mar. 43(3):169-70. [Medline].
Wang J, Palmer K, Lotvall J, et al. Circulating, but not local lung, IL-5 is required for the development of antigen-induced airways eosinophilia. J Clin Invest. 1998 Sep 15. 102(6):1132-41. [Medline]. [Full Text].
Wong-Waldamez A, Silva-Lizama E. Bullous larva migrans accompanied by Loeffler's syndrome. Int J Dermatol. 1995 Aug. 34(8):570-1. [Medline].