Disseminated Eosinophilic “Collagen Disease”

Eosinophilia and thrombophilia in churg strauss syndrome: a clinical and pathogenetic overview

During the past decade, there has been an increased description of Churg Strauss syndrome (CSS) characterized by vascular occlusions possibly linked to the thrombogenic potential of the eosinophil that is poorly appreciated. The purpose of this overview is 3-fold: the first to evaluate the available prevalence of thrombosis in Churg Strauss series, the second to demonstrate that any vascular district may be affected, and the third to describe the pathogenesis of thrombosis in CSS. A Pubmed, EMBASE, and Google search of CSS series from 1951 to date revealed a prevalence of arterial occlusion ranging between 3.1% and 18.7% and a prevalence of venous occlusion between 5.8% and 30%, whereas a specific survey for venous thromboembolism in CSS yielded a prevalence of 8.1%. Eosinophils store and release tissue factor as well as other cationic proteins: the former initiates coagulation while the latter inhibits natural anticoagulant activity and activate platelets eventually culminating in excessive thrombin generation and clot formation. In addition, antineutrophil cytoplasmic antibodies may shift the endothelial lining to proadhesive and prothrombotic surface. It is hoped that the review will represent a basis to foster novel research on this topic.

Rheumatoid arthritis, immune complex disease, and hypereosinophilic syndrome. Report on a case

A patient with typical rheumatoid arthritis is presented. After a short period of the disease a hyperosinophilic syndrome (HES) developed with vasculitis, pulmonary fibrosis, and thrombosis, and the disease took a malignant course. The patient died within a year after the diagnosis of HES. High titres of rheumatoid factor were manifested and total complement (CH50) was very low, indicating an active immune disease. As HES has been suggested to have an autoimmune aetiology, these findings are interesting, as positive rheumatoid serology has very rarely been reported in patients with this syndrome.

Different composition of the eosinophilic bone marrow pool in reactive eosinophilia and eosinophilic leukaemia

The composition of the eosinophilic cell series in the bone marrow has been analysed in 10 patients with a pronounced reactive eosinophilia (RE) and in 2 with eosinophilic leukaemia (EL). An imparied differentiation of the eosinophils was found in the EL patients compared with the RE group. Thus the ratio of eosinophilic promyelocytestmyelocytes: segmented eosinophils was 9.2 and 9.1, respectively, in the patients with EL and 0.1--3.1 (average 1.3) in the RE patients. It is suggested that EL is characterized by an impaired differentiation of the eosinophilic bone marrow cells and that the recognition of this abnormality is of value in the diffential diagnosis between EL and RE.

Treatment of hypereosinophilic syndromes with prednisone, hydroxyurea, and interferon

The hypereosinophilic syndromes continue to challenge our clinical acumen and skills. Prednisone, hydroxyurea, and interferon alpha 2b are three of the oldest agents that allow control of eosinophilia and its devastating clinical consequences. They still work. As our experience with them has grown, it has become evident that use of these agents in combination will control eosinophilia in most patients. Moreover, with time, the doses can frequently be reduced. Even with the advent of newer agents for treatment of hypereosinophilic syndromes, these three medications still afford an excellent, cost-effective avenue for disease management.

Eosinophilic vasculitis in connective tissue disease

BACKGROUND

Neutrophilic and lymphocytic vascular inflammation is common in vasculitis associated with connective tissue disease (CTD). We recently identified eight patients with CTD and eosinophilic vasculitis.

OBJECTIVE

The purpose of this study was to characterize a variant form of vasculitis in CTD with eosinophilic infiltration.

METHODS

Of 98 CTD patients with cutaneous necrotizing vasculitis, eight were found with predominantly eosinophilic vascular infiltration. Nine CTD patients with cutaneous neutrophilic vasculitis were identified for comparison. Clinical and laboratory findings were reviewed and compared. Indirect immunofluorescence for eosinophil granule major basic protein (MBP), neutrophil elastase, and mast cell tryptase was performed on lesional tissue. MBP levels and eosinophil survival enhancing activity were assayed in sera from three patients.

RESULTS

The patients with eosinophilic vasculitis had depressed serum complement levels and peripheral blood eosinophilia; MBP levels were elevated in serum and eosinophil survival was prolonged. Immunofluorescence of tissue showed marked angiocentric eosinophil MBP staining with peripheral neutrophil elastase staining; mast cell tryptase staining was notably absent. The patients with neutrophilic vasculitis were variably hypocomplementemic and did not have peripheral blood eosinophilia. Immunofluorescence showed marked angiocentric neutrophil elastase staining with scattered eosinophil MBP staining; mast cell tryptase staining showed normal mast cell numbers.

CONCLUSION

Patients with eosinophilic vasculitis, CTD, and hypocomplementemia show vessel wall destruction in association with vessel wall deposition of cytotoxic eosinophil granule MBP, which suggests that eosinophils mediate vascular damage in this disease process. In addition, perivascular mast cells appear diminished, thereby suggesting that mast cell degranulation occurs.

The idiopathic hypereosinophilic syndrome

A 14 year old girl with idiopathic hypereosinophilic syndrome is described. In addition to weight loss, anaemia, amenorrhoea, general lethargy, anorexia, mouth ulcers, blisters of hands and feet, and petechial skin rash, she had features of involvement of the cardiovascular system as the major complication. She responded well to treatment. After a comprehensive search of the published reports 18 cases of this syndrome were identified in children under 16 years. Fifteen of these children had involvement of the cardiovascular system as the major source of their morbidity and mortality. Summary of the clinical details and laboratory, biopsy, and necropsy findings of the involvement of the various organ systems of the 18 children is presented.

Atypical histiocytic granuloma. Light microscopic, ultrastructural, and histochemical findings in an unusual pseudomalignant reactive lesion of the oral cavity

Four cases of an ulcero-proliferative lesion of putative histiocytic origin, arising in the oral cavity, are described. This lesion, which has not been defined previously, is easily confused histologically with a malignant process of lymphoid origin, thereby representing a pseudolymphomatous proliferation. Light microscopic, ultrastructural, and histochemical characteristics including immunoglobulin negativity, positive esterase reactivity, and positive peanut lectin binding support a histiocytic origin. These lesions are not associated with systemic disease or dissemination and heal spontaneously despite their worrisome microscopic appearance.

Noncardiovascular findings associated with heart disease in the idiopathic hypereosinophilic syndrome

Heart disease characterized by endomyocardial fibrosis is one of the major causes of morbidity and mortality in the idiopathic hypereosinophilic syndrome. From our series of 50 patients with idiopathic hypereosinophilia, we defined the noncardiovascular characteristics that distinguish patients at risk of developing endomyocardial fibrosis from those who remain free of heart disease. These groups did not differ with respect to the extent of eosinophilia or the duration of disease. Patients with clinically overt heart disease were more likely (p less than 0.05) to be male and HLA-Bw44 positive and have splenomegaly, thrombocytopenia, elevated serum levels of vitamin B12, and hypogranular or vacuolated eosinophils and abnormal early myeloid precursors in the peripheral blood. These idiopathic hypereosinophilic patients with heart disease were also more likely to have fibrosis and decreased megakaryocytes in the bone marrow. In contrast, those who remained free of heart disease tended to be female and have angioedema, hypergammaglobulinemia, elevated serum levels of immunoglobulin E (IgE), and circulating immune complexes. Therefore, in the idiopathic hypereosinophilic syndrome, male patients with a myeloproliferative type disorder and the HLA-Bw44 haplotype were at a much increased risk for the development of endomyocardial fibrosis. However, those patients with a hypersensitivity-like illness and angioedema who were female did not develop heart disease. Appreciation of this relative degree of risk for the major complication of the idiopathic hypereosinophilic syndrome should prove useful in the early identification and appropriate treatment of patients in whom endomyocardial fibrosis might develop.

Renal lesions in the obliterative cardiomyopathies: endomyocardial fibrosis and Loffler's endocarditis

Electron and, or light microscopic examination of paraffin embedded renal tissue obtained from necropsies on eleven patients with obliterative cardiomyopathy showed a variety of abnormalities. Glomerular lesions present in patients with endomyocardial fibrosis included capillary wall thickening, basement membrane duplication, mesangial expansion and interposition, intraluminal fibrin and dense subendothelial deposits. These changes, some of which have been reported earlier in patients with Loffler's endocarditis, probably result from deposition and organisation of immune complexes.

[Eosinophilic fasciitis (Shulman syndrome)]

Scleroderma like skin indurations without internal organ involvement, joint contractures, eosinophilia, and inflammatory infiltration of the fascia between subcutis and muscle are considered as characteristic features of eosinophilic fasciitis (EF). We report a further case of a 30 years old diabetic confirming to the syndrome defined by Shulman 1974. Corticosteroid therapy resulted in remission of disease symptoms, however a rebiopsy revealed no effect of therapy on histopathologic changes. A critical review of 118 cases in the literature is presented to explore the relationship of EF to scleroderma.

Cardiomyopathy in a child with hypereosinophilic syndrome

A 9-year-old boy presented with increasing fatigue, anorexia, weight loss, fever, and absolute eosinophilia (48,000/microL). Pulmonary infiltrates occurred 3 months later. A murmur of mitral regurgitation was heard 5 months after onset of illness, and heart failure soon followed. Despite corticosteroid therapy the eosinophilia persisted intermittently until 1 month before death. The patient died within 9 months of the onset of illness. At necropsy there was cardiomegaly with subendocardial fibrosis in the right and left ventricles. Thrombi were present in the left ventricular apex and behind the posterior mitral leaflet. The findings in 12 previously reported pediatric cases are reviewed. The etiopathogenesis of the hypereosinophilic syndrome is discussed: half of the cases in children are associated with leukemia.

A spectrum of hypereosinophilic syndromes exemplified by six cats with eosinophilic enteritis

Of six cats with eosinophilic enteritis, two had lesions confined to the intestinal tract, and four had varied disseminated eosinophilic infiltration of other organs. The lesions in these cats are similar to those of the hypereosinophilic syndrome in man. A feline hypereosinophilic syndrome is proposed, consisting of eosinophilic enteritis, disseminated eosinophilic disease, and eosinophilic leukemia.

Endomyocardial disease and eosinophilia. Report of a case

While an association between blood eosinophilia and endomyocardial disease has been recognized, the role of the eosinophil in the pathogenesis of the cardiac lesions remains uncertain. In a 69-year-old-man with large cell carcinoma of the lung, marked eosinophilia was stimulated by and progressed with the course of the neoplasm which was producing an eosinophil chemotactic factor. Peripheral blood eosinophils were vacuolated and degranulated while those in the bone marrow were morphologically normal. Clinical evidence of cardiac dysfunction developed one month prior to death. At autopsy, 12 months after the onset of symptoms, endomyocardial disease was present. There were numerous eosinophils in the damaged myocardium and surrounding the pulmonary neoplasm. In patients with endomyocardial disease and eosinophilia, the eosinophil may be directly cardiotoxic or a primary mediator of cardiac damage; therapeutic attempts to reduce the number of eosinophils might be benefit.

Trichinosis causing extensive ventricular mural endocarditis with superimposed thrombosis. Evidence that severe eosinophilia damages endocardium

Clinical and morphologic observations are described in a 46 year old woman with fatal trichinosis. Attention is called to the occurrence of extensive ventricular endocardial damage with superimposed thrombosis; Evidence is presented to indicate that the most likely cause of the endocardial damage is the associated eosinophilia. The mechanism by which eosinophils damage endocardium, however, remains obscure.

Löffler's endocarditis and endomyocardial fibrosis--a nosologic entity?

The problem whether Löffler's endocarditis and endomyocardial fibrosis belong to the same disease spectrum or are separate entities is still under debate. Until recently it was believed that endomyocardial fibrosis was a disorder restricted to tropical areas. Three Danish patients are presented, two showing a continuous disease spectrum, one patient showing the fully developed endomyocardial fibrosis which is indistinguishable from endomyocardial fibrosis described from the tropical areas. Eosinophilia was present in all three patients. The findings described in these three patients lend support to the unitarian hypothesis that Löffler's endocarditis and endomyocardial fibrosis belong to the same disease spectrum, and that the eosinophilic granulocyte may be the underlying cause.

Unique eosinophil granules in a case of T-cell lymphoma

A 41-year-old man developed intense itching without visible cutaneous changes, epigastric pressure pain, and a slight intolerance to alcohol. He was found to have persistent blood eosinophilia. The eosinophil granulocytes were of abnormal appearance in the light microscope: larger than normal, the nuclei were multilobulated (4-6 lobes), the cytoplasm contained atypical, large granules, ample glycogen, and up to 12 vacuoles. In the electron microscope too the eosinophil granules were entirely atypical, having an electron-dense matrix, often with a light central inclusion body which was inhomogeneous, having longitudinally oriented structures with a periodicity of about 10 nm. These findings are quite contrary to normal eosinophil granules. Enzymic studies of cytoplasmic enzymes from the granulocytes revealed a greatly reduced content of eosinophil cationic proteins, whereas 5 (7) other enzymes were present in a normal or slightly reduced quantity. The phagocytic capacity of the eosinophils against latex particles was normal. The patient developed generalized lymphomas, histologically very malignant, of the convoluted, acid phosphatase positive cell type (T-cell lymphoma). Sub-population studies of lymphocytes from a lymph node revealed 58% TE cells, while the remainder were B cells. At death, 3-1/2 years after the onset of symptoms, severe endomyocardial fibrosis was found. The thymus could not be identified. It is concluded that lymphomas should be described on the bais of clinical, histological, and histochemical criteria as well as studies of lymphocyte sub-populations and that the highly unusual eosinophil granulocytes still deserve particular attention. The endocardial fibrosis is assumed to have been due to substances liberated from the eosinophil cells.

Hypereosinophilic multiple thrombosis. A proposal of a new designation of disseminated eosinophilic "collagen disease"

A case of marked chronic mature eosinophilia associated with multiple thrombosis in 30-year-old male is presented. Hitherto this sort of the disease has been categorized as DECD. Reviewing the autopsied cases of DECD, including our own case, DECD should not be categorized as a collagen disease because of the absent connective tissue degeneration and absent connective tissue degeneration and absent serological abnormalities. We rather noticed a certain relation between marked chronic mature eosinophilia and thrombus formation. Therefore, we propose here the term hypereosinophilic multiple thrombosis to express the pathomorphogenesis more precisely.

Ph1-negative eosinophilic leukaemia with trisomy 8. Case report and review of cytogenetic studies

A case of eosinophilic leukaemia of the mature cell type in a 73-year-old man is described. Bone marrow chromosomes were studied in direct preparations on 3 occasions. With the G- and Q-banding techniques an extra chromosome number 8 was observed in all metaphases. There was no Ph1-chromosome. Therapy with vincristine and prednisone produced remissions but the course of the disease was accelerated. Review of the literature and study of the present case suggests that eosinophilic leukaemia like CGL may be divided into a Ph1-positive and a Ph1-negative group. In both groups karyotype abnormalities may be present and might herald a downhill course.

Bronchial carcinoma with eosinophilia and cardiomegaly

A patient with a giant cell carcinoma of the bronchus presented with headache and flushing attacks and a blood eosinophilia. He developed a right bundle branch block and later congestive cardiac failure. At post mortem he was found to have the appearance of Loeffler's endocarditis. A tentative mechanism for these events is proposed.

Eosinophilic leukemia. Remission with vincristine and hydroxyurea

A 40 year old man with eosinophilic leukemia was treated with a variety of chemotherapeutic agents. A long-term remission, unusual for eosinophilic leukemia, was maintained with chronic hydroxyurea therapy after induction with vincristine. Hydroxyurea and vincristine may offer an effective mode of therapy for this disease.

Serum vitamin B12-binding proteins in a case of eosinophilic leukemia

A patient with subacute eosinophilic leukemia is presented, with full recognition of the controversy surrounding that entity. Serum vitamin B12 and B12-binding protein studies and simultaneous complete blood counts were done before and during 6 months of high-dose, intermittent combination chemotherapy. The patient presented with extremely high levels of serum vitamin B12, unsaturated B12-binding capacity, and transcobalamin I, all of which resembled the highest values seen in chronic myelogenous leukemia. Serial studies, during and after remission induction, showed a precipitous fall of serum vitamin B12 and unsaturated B12-binding capacity to normal levels. The data show that transcobalamin I levels, which eventually reached low-normal range, correlate best with the level of circulating and bone marrow eosinophils. Transcobalamin II and serum third binder appeared to be normal throughout the patient's course. The B12-binding protein abnormalities are not considered diagnostic of eosinophilic leukemia.

[On the ultrastructure and cytochemistry of eosinophil-myelomonocytic leukemias]

In the bone marrow of two patients with acute leukemia 46% and 55% of atypical eosinophilic cells were found, respectively. Blood eosinophilia was absent. The N-AS-D-Cl-Esterase reaction of the granules was positive in the first case in 58%, and in the second case in 3% of the eosinophils, as well as the PAS-reaction in all cells of this series. The ultrastructure of the eosinophils reveals nuclear maturation up to hypersegmentation. The maturation of the granules, in part of abnormal size, is arrested at the primary stage. Typical secondary granules with cristalloid cores are lacking. Only in the first case a few, small, semicircular or circular profiles of lamellar substructure are seen in the granules. The cytoplasm of hypersegmentated eosinophils shows an abnormally high glycogen content. Besides the eosinophils, monocytic cells and their precursors proliferate in the bone marrow of the first patient. In the second patient myeloblasts, promyelocytes with Auer rods, and monocytic cells characterize further neoplastic cell population. The elements of the monocytic series can be identified by their ultrastructural features, such as irregular configuration of the nuclei, bundles of cytoplasmatic microfilaments, and numerous small electron-dense lysosomal granules. In both cases the Alpha-Naphthyl-Acetase-Esterase reaction is weakly positive. The findings presented are summarized under the terms "eosinophil-monocytic leukemia" and "eosinophil-myelomonocytic leukemia" (collective term).

Eosinophilic leukaemia terminating with an encephalopathy

A 52-year-old man developed an illness which lasted for 2 years until its fatal termination. It comprised in chronological order: mild asthma, skin irritation, mature eosinophilia in the peripheral blood, and finally an encephalopathy. The diagnostic problem of distinguishing between eosinophilic leukaemia and an eosinophilic leukaemoid reaction is discussed. The cause of the encephalopathy was discovered at autopsy to be a widespread intravascular thrombotic process. The question of future possible therapy is discussed.