eMedicine Specialties > Hematology > Immune System and Disorders

Eosinophilia: Differential Diagnoses & Workup

Author: Michaelann Liss, DO, Consulting Staff, Department of Hematology/Oncology, The Vancouver Clinic/ South West Washington Medical Center
Coauthor(s): Erik Zeger, MD, Consulting Staff, Main Line Oncology Hematology Associates; Daniel R Lucey, MD, MPH, Chief, Fellowship Program Director, Department of Internal Medicine, Division of Infectious Diseases, Washington Hospital Center; Professor, Department of Internal Medicine, Uniformed Services University of the Health Sciences; Palaniandy Kogulan, MBBS, MD, Assistant Director of Internal Medicine, Synergy Medical Education Alliance; Assistant Professor of Medicine, Michigan State University College of Human Medicine
Contributor Information and Disclosures

Updated: May 21, 2009

Workup

Laboratory Studies

  • Complete blood cell (CBC) count with differential to quantitate the percentage eosinophils and absolute number of eosinophils (AEC).
  • Blood chemistries can indicate specific organ involvement (ie, liver, kidney).
  • Spinal fluid examination to assess the cerebrospinal fluid (CSF) eosinophilia due to worm infections (eg, Angiostrongylus cantonensis), drug reactions (eg, Dilantin), and coccidioidomycosis fungal meningitis.
  • Patients with allergic symptoms should have a nasal smear for eosinophilia and Gram stain. Patients with asthma symptoms should have sputum examination for eosinophilia.
  • In suspected cases of medication and some parasitic infections, evaluation of urine sediment may be helpful. Stool samples should be evaluated for ova and parasites if indicated by history.
  • If reactive causes are unlikely, a bone marrow biopsy should be done. Clues of clonality in peripheral blood include macrocytosis, thrombocytosis, left-shifted granulopoiesis and circulating blasts. In the bone marrow, myeloproliferation with dyshematopoiesis and reticulin fibrosis are suggestive of clonality. Staining for tryptase and immunophenotyping should be done. If primary eosinophilia is suspected, fluorescent in situ hybridization (FISH) or reverse transcriptase-polymerase chain reaction (RT-PCR) is sent to detect fusion genes. FISH for the CHIC2 gene deletion can also give a presumptive diagnosis of a fusion gene. T-cell receptor gene rearrangement can be evaluated by flow cytometry. Elevated serum levels of tryptase (seen in systemic mastocytosis [SM]), IL-5 (common in clonal T-cell disorders) and IgE can also be measured for elevation.

Imaging Studies

  • Computed tomography (CT) scanning
    • CT scans of the lungs, abdomen, pelvis, and brain evaluate for focal defects due to diverse causes of eosinophilia.
    • Worm infections of the liver (eg, Fasciola hepatica) can cause focal hepatic lesions.
    • A coccidioidomycosis fungal infection can cause focal lesions in the lung, which are visible on a chest radiograph or CT scan.
    • Hodgkin or non-Hodgkin lymphoma can cause adenopathy in the abdomen, which is visualized on a CT scan.
  • Echocardiogram to assess for thrombi (eg, mural, endocardial) due to hypereosinophilic syndrome (HES).

Procedures

  • A bone marrow biopsy may be helpful (see Laboratory Studies).
  • A lumbar puncture may be performed to evaluate spinal fluid for CSF eosinophilia. CSF eosinophilia may be due to worm infections (eg, A cantonensis), drug reactions, or coccidioidomycosis fungal meningitis.
  • Schistosoma hematobium typically causes eosinophilia and hematuria due to infection of the bladder. All patients with blood eosinophilia who have lived or traveled in Africa and have either gross or microscopic hematuria should have their urine examined for the eggs of S hematobium. Cystoscopy is usually necessary to make the diagnosis, because the terminal-spined eggs of this species of schistosome can often be found in the urine if specifically sought.
    Egg of <i>Schistosoma hematobium</i>, with its ty...

    Egg of Schistosoma hematobium, with its typical terminal spine.

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    Egg of <i>Schistosoma hematobium</i>, with its ty...

    Egg of Schistosoma hematobium, with its typical terminal spine.

More on Eosinophilia

Overview: Eosinophilia
Differential Diagnoses & Workup: Eosinophilia
Treatment & Medication: Eosinophilia
Follow-up: Eosinophilia
Multimedia: Eosinophilia
References
Further Reading
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References

  1. Spry CJF, ed. Eosinophils: A Comprehensive Review and Guide to the Scientific and Medical Literature. Oxford, UK: Oxford University Press; 1988.

  2. Gotlib J. Molecular classification and pathogenesis of eosinophilic disorders: 2005 update. Acta Haematol. 2005;114(1):7-25. [Medline].

  3. Tefferi A, Patnaik MM, Pardanani A. Eosinophilia: secondary, clonal and idiopathic. Br J Haematol. Jun 2006;133(5):468-92. [Medline].

  4. Weller PF, Bubley GJ. The idiopathic hypereosinophilic syndrome. Blood. May 15 1994;83(10):2759-79. [Medline]. [Full Text].

  5. Bain BJ. Relationship between idiopathic hypereosinophilic syndrome, eosinophilic leukemia, and systemic mastocytosis. Am J Hematol. Sep 2004;77(1):82-5. [Medline]. [Full Text].

  6. Gotlib J, Cools J, Malone JM 3rd, et al. The FIP1L1-PDGFRalpha fusion tyrosine kinase in hypereosinophilic syndrome and chronic eosinophilic leukemia: implications for diagnosis, classification, and management. Blood. Apr 15 2004;103(8):2879-91. [Medline]. [Full Text].

  7. Tefferi A. Modern diagnosis and treatment of primary eosinophilia. Acta Haematol. 2005;114(1):52-60. [Medline].

  8. Fletcher S, Bain B. Eosinophilic leukaemia. Br Med Bull. 2007;81-2:115-27. [Medline]. [Full Text].

  9. Weller PF. Eosinophilia in travelers. Med Clin North Am. Nov 1992;76(6):1413-32. [Medline].

  10. Jain N, Cortes J, Quintas-Cardama A, et al. Imatinib has limited therapeutic activity for hypereosinophilic syndrome patients with unknown or negative PDGFRalpha mutation status. Leuk Res. Jun 2009;33(6):837-9. [Medline].

  11. Allen JN, Davis WB. Eosinophilic lung diseases. Am J Respir Crit Care Med. Nov 1994;150(5 Pt 1):1423-38. [Medline].

  12. Butterfield JH. Success of short-term, higher-dose imatinib mesylate to induce clinical response in FIP1L1-PDGFRalpha-negative hypereosinophilic syndrome. Leuk Res. Aug 2009;33(8):1127-9. [Medline].

  13. Cohen AJ, Steigbigel RT. Eosinophilia in patients infected with human immunodeficiency virus. J Infect Dis. Sep 1996;174(3):615-8. [Medline].

  14. Cortes J, Ault P, Koller C, et al. Efficacy of imatinib mesylate in the treatment of idiopathic hypereosinophilic syndrome. Blood. Jun 15 2003;101(12):4714-6. [Medline]. [Full Text].

  15. Fink SR, Belongie KJ, Paternoster SF, et al. Validation of a new three-color fluorescence in situ hybridization (FISH) method to detect CHIC2 deletion, FIP1L1/PDGFRA fusion and PDGFRA translocations. Leuk Res. Jun 2009;33(6):843-6. [Medline].

  16. Heimall J, Freeman A, Holland SM. Pathogenesis of hyper IgE syndrome. Clin Rev Allergy Immunol. May 19 2009;epub ahead of print. [Medline].

  17. Lucey DR, Clerici M, Shearer GM. Type 1 and type 2 cytokine dysregulation in human infectious, neoplastic, and inflammatory diseases. Clin Microbiol Rev. Oct 1996;9(4):532-62. [Medline]. [Full Text].

  18. [Best Evidence] [Best Evidence] Nair P, Pizzichini MM, Kjarsgaard M, et al. Mepolizumab for prednisone-dependent asthma with sputum eosinophilia. N Engl J Med. Mar 5 2009;360(10):985-93. [Medline].

  19. Nand R, Bryke C, Kroft SH, et al. Myeloproliferative disorder with eosinophilia and ETV6-ABL gene rearrangement: efficacy of second-generation tyrosine kinase inhibitors. Leuk Res. Aug 2009;33(8):1144-6. [Medline].

  20. Roufosse F, Goldman M, Cogan E. Hypereosinophilic syndrome: lymphoproliferative and myeloproliferative variants. Semin Respir Crit Care Med. Apr 2006;27(2):158-70. [Medline].

  21. Tefferi A, Pardanani A. Imatinib therapy in clonal eosinophilic disorders, including systemic mastocytosis. Int J Hematol. Jun 2004;79(5):441-7. [Medline].

  22. Tostes Oliveira D, Tjioe KC, et al. Tissue eosinophilia and its association with tumoral invasion of oral cancer. Int J Surg Pathol. Jul 2009;17(3):244-9. [Medline].

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Further Reading

Related eMedicine Topics

Clinical Trials
National Guideline Clearinghouse

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Keywords

eosinophilia, eosinophilic leukocytes, idiopathic hypereosinophilic syndrome, HES, CHINA, Ascaris lumbricoides, Loffler syndrome, simple pulmonary eosinophilia, tropical eosinophilia, angiolymphoid hyperplasia with eosinophilia, eosinophilia-myalgia syndrome, leukocyte disorders, helminthic infection

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Contributor Information and Disclosures

Author

Michaelann Liss, DO, Consulting Staff, Department of Hematology/Oncology, The Vancouver Clinic/ South West Washington Medical Center
Michaelann Liss, DO is a member of the following medical societies: American College of Physicians, American Medical Association, American Osteopathic Association, American Physical Therapy Association, American Society of Hematology, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Erik Zeger, MD, Consulting Staff, Main Line Oncology Hematology Associates
Erik Zeger, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, and American Society of Hematology
Disclosure: Nothing to disclose.

Daniel R Lucey, MD, MPH, Chief, Fellowship Program Director, Department of Internal Medicine, Division of Infectious Diseases, Washington Hospital Center; Professor, Department of Internal Medicine, Uniformed Services University of the Health Sciences
Daniel R Lucey, MD, MPH is a member of the following medical societies: Alpha Omega Alpha and American College of Physicians
Disclosure: Nothing to disclose.

Palaniandy Kogulan, MBBS, MD, Assistant Director of Internal Medicine, Synergy Medical Education Alliance; Assistant Professor of Medicine, Michigan State University College of Human Medicine
Palaniandy Kogulan, MBBS, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Pradyumna D Phatak, MBBS, MD,, Chair, Division of Hematology and Medical Oncology, Rochester General Hospital; Clinical Professor of Oncology, Roswell Park Cancer Institute
Pradyumna D Phatak, MBBS, MD, is a member of the following medical societies: American Society of Hematology
Disclosure: Novartis Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Marcel E Conrad, MD, (Retired) Distinguished Professor of Medicine, University of South Alabama
Marcel E Conrad, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Association of Blood Banks, American Chemical Society, American College of Physicians, American Physiological Society, American Society for Clinical Investigation, American Society of Hematology, Association of American Physicians, Association of Military Surgeons of the US, International Society of Hematology, Society for Experimental Biology and Medicine, and Southwest Oncology Group
Disclosure: No financial interests None None

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD, Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Thomas Jefferson University
Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, and New York Academy of Sciences
Disclosure: Nothing to disclose.

 
 
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