Co-occurrence of Idiopathic Hypereosinophilic Syndrome in End-Stage Renal Disease Patients Undergoing Maintenance Hemodialysis

Hypereosinophilic syndrome (HES) is defined as the presence of (1) peripheral blood eosinophilia >1.5 x 109/L for at least one month, (2) evidence of eosinophil-mediated organ damage and/or dysfunction, and (3) exclusion of other potential causes of eosinophilia. In hemodialysis patients, HES has been associated with manifestations because of low blood pressure or gastrointestinal symptoms that result in dialysis intolerance. Very few cases of HES co-occurrence in dialysis patients have been reported in the literature, and their clinical characteristics are not fully understood. Here, we report two end-stage renal disease patients diagnosed with idiopathic HES while undergoing maintenance hemodialysis. The first patient presented with unexplained persistent pruritus and intradialytic hypotension, which started 10 minutes after the dialysis session initiation. Hematologic studies revealed hypereosinophilia which remarkably improved on steroid therapy. The second patient was accidentally discovered with asymptomatic persistent hypereosinophilia. His blood counts improved initially on interferon treatment before achieving full remission on steroid therapy. Neither of the two patients reported any history of allergy or atopic manifestations. Our case report sheds light on the possible occurrence of HES in hemodialysis patients which may be confused with other dialysis-related complications. Although steroids remain the mainstay of treatment, the optimal dose and duration of treatment remain unknown.

Eosinophilic Fasciitis in a 68-Year-Old Female

Eosinophilic fasciitis (EF) is an uncommon disorder of unknown etiology and poorly understood pathogenesis. In this report, we present a case of a 68-year-old female presented with a rapidly progressing skin tightening condition in her extremities associated with eosinophilia. Four months prior, the patient's initial complaint was skin sensitivity in the legs and forearms. Over time, this led to severe skin tightening, edema, and decreased range of motion. Clinical examination showed tightening of the skin over the anterior forearms, posterior knees, and calves without sclerodactyly or Raynaud's phenomenon. Laboratory investigations showed eosinophilia, elevated antinuclear antibody titer, and negative rheumatoid factor. This presentation raised suspicion of EF, and biopsy results showed scattered lymphocytic infiltrate involving associated fibrous tissue and perivascular lymphocytic inflammation that involved vessel walls. She was treated with low-dose steroids due to her diabetes but the stiffness continued. She was started with immunomodulators methotrexate, which showed improvement in symptoms, including softening in her arm tissues.

Association between peripheral eosinophilia, JESREC score, and olfactory dysfunction in patients with chronic rhinosinusitis

Objective

The purpose was to evaluate the relationship between peripheral eosinophilia, Japan Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis (JESREC) score, and olfactory dysfunction in chronic rhinosinusitis (CRS) patients and to explore the accuracy and specific cut points of the JESREC score in predicting olfactory dysfunction.

Methods

In this cross-sectional, retrospective study, olfactory function was assessed by the Sniffin' Sticks 12-item test and multivariate logistic regression analyses were carried out. Receiver operating characteristic curves were plotted to derive accuracy and cutoff values for the JESREC scores of the olfactory dysfunction criterion.

Results

A total of 354 patients [mean (SD) age, 50.0 (14.9) years; 41.8% women] were included in the final analysis. The prevalence of olfactory dysfunction was 46.3%. Individuals who had olfactory dysfunction were more likely to be male (64.6% vs. 52.6%), have eosinophilic chronic rhinosinusitis (ECRS) (39.0% vs. 7.9%), have a longer course of CRS (2.3 years vs. 1.5 years), have higher JESREC scores (8.5 vs. 4.5), and have higher proportions of nasal polyps (78.7% vs. 18.9%) and peripheral eosinophilia (3.3% vs. 1.4%). In logistic analysis, the percentage of eosinophils (1.25, 1.13-1.37), JESREC score (1.31, 1.22-1.40), bilateral lesion (2.06, 1.25-3.41), nasal polyps (15.83, 9.23-27.16), CT shadow (2.73, 1.69-4.43), and ECRS (6.86, 3.68-12.80) were associated with olfactory dysfunction in CRS patients after controlling for covariates, while peripheral neutrophils were not significant. In addition, the area under the curve was 0.778 and the cutoff value for JESREC score for olfactory dysfunction was defined as 5.5.

Conclusions

Peripheral eosinophilia and high JESREC scores were significantly associated with the risk of olfactory dysfunction in CRS patients, and special attention should be paid to patients with a JESREC score ≥6.

Tuberculosis manifesting with significant peripheral eosinophilia: A case report and review of literature

Key Clinical Message

Peripheral eosinophilia is a rare but potential sign of TB infection. Physicians should assess patients for TB, especially if they display related symptoms or risk factors, and consider TB as a differential diagnosis, especially in idiopathic cases.

Abstract

Millions of new tuberculosis (TB) cases are reported annually. Peripheral eosinophilia is rare in tuberculosis. We describe a rare case of tuberculosis with a high peripheral eosinophil count. A 9-year-old male presented with fever, cough, and respiratory discomfort for a month. The patient's cough did not respond to treatment, along with weight loss and a loss of appetite. A physical examination revealed cervical lymphadenopathy and bilateral lung crepitations. A hematological investigation showed a high eosinophil count of 25,920 cells per cubic millimeter and medical imaging abnormalities consistent with TB. Some malignancies, allergies, and parasitic infections produce peripheral eosinophilia. However, medical literature rarely discusses TB-induced eosinophilia. Several studies attribute it to mycobacterium antigen hyperreactivity. Eosinophilic release of cytotoxic chemicals may cause tissue damage, and TB patients' eosinophil levels may fluctuate. This case report emphasizes the need to investigate TB in peripheral eosinophilia patients after ruling out other explanations. Our patient benefited from early detection and anti-TB medication. More studies are required to investigate the causes of TB eosinophilia and its consequences. A detailed medical history and physical examination are essential to diagnose and treat atypical presentations of TB.

Targeting IL-4 and IL-13 Receptors on Eosinophils in CRSwNP Patients: The Clinical Efficacy of Dupilumab

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is an inflammatory disease linked to type 2 inflammation. Several biologics have demonstrated therapeutic potential for the treatment of this pathology in which IL-4, IL-5 and IL-13 represent the major cytokines involved in the control of eosinophilic respiratory inflammation. 25% of CRSwNP patients relapse after the use of oral glucocorticoids or after surgery and often require several surgeries during their lifetime. In our study we enrolled 14 patients, 11 male and 3 female. The inclusion criteria were: age ≥ 18 years; confirmed diagnosis of chronic rhinosinusitis with severe nasal polyposis; disease severity with NPS Nasal Polyposis Endoscopic Score total score ≥ 5 and/or SNOT-22 ≥ 50; previous treatment failure due to lack of efficacy or discontinuation of systemic corticosteroid therapy and/or non-response or recurrence following surgery. The results presented in this study showed the ability of Dupilumab to improve all the parameters analysed. In particular, statistically significant data were obtained for NPS, SNOT-22, NRS, and IgE in patients exposed to Dupilumab treatment for 24 weeks, highlighting the ability of Dupilumab to produce clinical benefit in CRWwNP patients. In light of these data, the administration of dupilumab every two weeks represents a valid clinical strategy that ENT specialists can adopt for the treatment of adults with inadequately controlled CRSwNP.

A Case of Tropical Pulmonary Eosinophilia With Incomplete Response to Diethylcarbamazine Therapy

Tropical pulmonary eosinophilia (TPE) is a specific pulmonary manifestation of lymphatic filariasis. There is overwhelming infiltration of eosinophils in the lung parenchyma in response to microfilaria. The characteristic features include paroxysmal respiratory symptoms, strikingly high blood eosinophil count, elevated level of immunoglobulin (Ig) E along with high titer of anti-filarial antibody. Treatment with diethylcarbamazine (DEC) has an excellent favorable response. However, recovery may often be incomplete. We present a case of a 36-year-old man with TPE who had complete symptomatic improvement after a three-week course of DEC, but only a partial response in radiological and pulmonary function abnormalities.

Optic neuropathy caused by orbital Kimura disease: A rare case report

RATIONALE

Kimura disease (KD) is a rare, chronic inflammatory disease characterized by painless subcutaneous nodules predominantly located in the head and neck regions. Orbital KD, which intrudes into the intraconal space and results in compressive optic neuropathy, is rare and has not been previously reported.

PATIENT CONCERNS

A 68-year-old man presented with blurred vision and progressive proptosis in the left eye that had been present for 2 years.

DIAGNOSIS

Magnetic resonance imaging of the brain revealed soft tissue lesions with contrast enhancement and restricted diffusion involving the bilateral eyelids, orbits, and intraconal region; those on the left side were more prominent than those on the right side. The lesion encased the left optic nerve. Laboratory test results revealed elevated serum immunoglobulin E level and peripheral eosinophilia. An orbital mass biopsy demonstrated hyperplastic lymphoid follicles with germinal centers in the subcutaneous area and abundant mononuclear and binuclear eosinophils infiltrating the interfollicular area. A pathological diagnosis of KD was made based on the blood test results.

INTERVENTIONS

Orbital decompression and debulking surgery of the orbital tumor in the left eye were performed to treat the compressive optic neuropathy.

OUTCOMES

After systemic oral steroid and immunosuppressive agent therapies, the patient's visual acuity in the left eye improved, and the KD activity was stable.

CONCLUSIONS

We present a rare case of orbital KD-associated optic neuropathy, wherein early diagnosis and treatment preserved the patient's vision. This complication should be considered in patients with a history of compressive optic neuropathy during the differential diagnosis.

Latent Strongyloides stercoralis in an Asymptomatic Male With Chronic Peripheral Eosinophilia

Peripheral eosinophilia is a potentially concerning finding that can occur due to a multitude of causes. One such cause is latent helminth infections such as Strongyloides stercoralis. These parasites have broad distributions throughout the developing world, particularly South and Southeast Asia and it is estimated that roughly 200 million people have latent infections. We present the case of a 74-year-old patient from India who had asymptomatic eosinophilia since before 2006. He previously underwent an extensive workup which included testing for neoplasms, gene mutations, and lymphoproliferative disorders. After carefully examining the patient's travel history and demographic information, a parasite panel was administered which was positive for Strongyloides, thereby establishing a cause for his condition after years of expensive testing. Latent Strongyloides infections can lead to fatal dissemination if the host becomes immunocompromised. It is therefore essential to keep a detailed history of patient travel, occupation, and functional status when assessing peripheral eosinophilia so that obvious causes are not overlooked.

Peripheral Blood Eosinophilia and Long-term Severity in Pediatric-Onset Inflammatory Bowel Disease

BACKGROUND

Peripheral blood eosinophilia (PBE) is a biomarker of an aggressive multiyear natural history in adults with inflammatory bowel diseases (IBDs). Additionally, PBE at diagnosis is associated with higher disease activity in pediatric-onset IBD. We sought to determine if PBE can function as a biomarker of long-term disease severity in pediatric-onset IBD patients who are followed into adulthood.

METHODS

We analyzed a consented, prospective, natural history IBD registry at an adult tertiary center from 2009 to 2018. Prevalence of PBE was evaluated in both pediatric- and adult-onset IBD patients. Demographics, clinical characteristics, and health care utilization data were compared in patients with and without PBE.

RESULTS

Among 2800 adult IBD patients, 23.4% had pediatric-onset disease. PBE was found in 34% of the pediatric-onset patients compared with 26.8% of the adult-onset IBD patients (P < 0.001). In the pediatric-onset IBD cohort, PBE was associated with higher rates of allergies (P < 0.0001), but not of asthma, allergic rhinitis, or primary sclerosing cholangitis. In the adult IBD patients with pediatric-onset disease, PBE was associated with higher rates of C-reactive protein elevation (P < 0.0001), erythrocyte sedimentation rate elevation (P < 0.0001), higher health care utilization, and higher average health care charges per year (P < 0.00001).

CONCLUSIONS

Peripheral blood eosinophilia was more prevalent in adult IBD patients with pediatric-onset compared with adult-onset disease. Among all IBD patients with long-term follow-up, PBE defined a subgroup with more severe illness. These data suggest that PBE may be a biomarker for a high-risk subgroup with high cost trajectory and long-term severity in pediatric-onset IBD that persists into adulthood.

Recurrent cutaneous necrotising eosinophilic vasculitis

Recurrent cutaneous necrotising eosinophilic vasculitis (RCNEV) is a rare disease that was first described in 1994. We report a case of RCNEV treated with corticosteroid, and 18 cases that we identified in the literature. Our review of the literature shows that RCNEV was frequently identified in middle-aged females from Asia and usually presents as erythematous to purpuric papuloplaques, angio-oedema on the extremities, as well as peripheral eosinophilia. Histopathologically, RCNEV is characterised by exclusively eosinophilic infiltration around the vascular plexus, the absence of leukocytoclasis and fibrinoid degeneration of vascular walls. Although, RCNEV responds to corticosteroid treatment, relapses have occurred during dose tapering. We also discuss the mechanisms of vascular destruction, the differential diagnosis and steroid-sparing therapies for RCNEV.

Non-Infectious Diseases Compatible With COVID-19 Pneumonia

While the definitive diagnosis of the coronavirus disease 19 (COVID-19) is mainly made by the polymerase chain reaction (PCR), some PCR-negative cases are diagnosed typically by a computed tomography (CT) scan's radiology. However, there are many different infectious and non-infectious diseases that have radiology like COVID-19. We are presenting a case of a patient having symptoms and a CT scan radiology comparable to that of COVID-19 and also having eosinophilia. The patient was initially diagnosed and treated as a COVID-19 patient. The patient stated that she had always complained of having dyspnea and cough, but it had increased even more in the past few days. Her thorax CT revealed bilateral ground-glass opacities with upper lobe predominance, which was reported as highly compatible with COVID-19 by radiologists. COVID-19 PCR result was negative twice. In laboratory results, eosinophil count was 2,850/mm³ and total Ig was 768 IU/mL. However, when the laboratory values and the radiological findings were combined with the patient’s history, COVID-19 was excluded and the chronic eosinophilic pneumonia was accepted as a diagnosis. Clinicians more focused on COVID-19 while questioning the patients and while evaluating the laboratory and the radiological findings make it easier to miss other infectious and non-infectious diseases. Assessing the complete blood count result, focusing on the lymphocyte value, also makes it easy to skip eosinophilia.

Eosinophilic Meningitis: Report of Three Cases from a Hilly Area in Kerala

Normal cerebrospinal fluid (CSF) does not contain eosinophils. The presence of >10 eosinophils/μL in CSF or at least 10% eosinophils in total CSF leukocyte count confirms eosinophilic meningitis. We present three patients with eosinophilic meningitis from the same locality with peripheral eosinophilia.

Peripheral Eosinophilia Found in Pediatric Enterobius vermicularis Infections

Enterobius vermicularis, the common pinworm, is well known in North America as a parasitic infection, mainly affecting children. It is a very contagious organism, and it is responsible for a high number of infections in the United States each year. A rise in eosinophilia is linked to most parasitic infections. However, the correlation between eosinophilia and enterobiasis infections is not well documented in the literature. In this article, we present 3 cases involving patients seen for pediatric gastroenterology consultation with concern for inflammatory bowel disease. As part of their evaluation, each patient was found to have eosinophilia of unknown significance with an ultimate diagnosis of pinworm infections made by endoscopy. Their illness presentation did not include classic enterobiasis symptoms such as rectal pruritus or nighttime irritability. These cases support a link between eosinophilia and enterobiasis that may be instructive for pediatric providers seeing patients with eosinophilia for which there is no readily apparent underlying cause.

Acute eosinophilic pneumonia associated with smoking: a case report

Acute eosinophilic pneumonia (AEP) is commonly misdiagnosed as infectious pneumonia due to presence of fever and radiological features. However, development of peripheral eosinophilia within days of presentation should raise the concern of AEP especially in previously heathy adults with history of recent tobacco smoking.

Eosinophilic and non-eosinophilic COPD patients with chronic respiratory failure: neutrophil-to-lymphocyte ratio as an exacerbation marker

Aim

Increased dyspnea, sputum volume, and purulence are subjective symptoms in COPD patients. To diagnose COPD exacerbations with chronic respiratory failure (CRF) and to assess the requirement for antibiotic treatment, physicians require more objective criteria. We aimed to investigate whether neutrophil-to-lymphocyte ratio (NLR) can be used as an infectious exacerbation marker in COPD patients with CRF.

Patients and methods

This retrospective cross-sectional study was performed in the intensive care outpatient clinic of a tertiary training hospital between 2014 and 2015. Patients admitted with CRF due to COPD and who had complete blood count (CBC) results were enrolled. CBC results and C-reactive protein (CRP) levels were obtained from the hospital online database. The “modified exacerbation model (MEM)” was defined as follows: exacerbation A, leukocytes ≥12,000/mm³, CRP >10 mg/dL; exacerbation B, leukocytes ≥10,000/mm³, CRP >10 mg/dL; exacerbation C, leukocytes ≥10,000/mm³, CRP >8 mg/dL; exacerbation D, leukocytes ≥10,000/mm³, CRP >5 mg/dL. The cutoff value of NLR was defined for each model. Patients were split into two groups based on the NLR cutoff value according to the “NLR exacerbation model” and further subgrouped according to peripheral eosinophil percentage (eosinophils ≥2% and <2%) and compared with the MEM.

Results

A total of 1,066 COPD patients (430 females, 40.3%), with a mean age of 66±13 years, were included. A NLR cutoff value of 3.54 (NLR ≥3.54, n=366, 34%) showed the highest sensitivity and specificity for model A (78%, 69%), model B (63%, 71%), model C (61%, 72%), and model D (58%, 72%). Peripheral eosinophilia (PE ≥2%) was present in 48 patients (4.5%). The ratio of patients with PE <2% in the NLR ≥3.54 group was significantly higher in the MEM (P<0.001).

Conclusion

The NLR presents an attractive option as an exacerbation marker in COPD patients with CRF due to its simplicity and cost-effectiveness. In COPD patients with CRF, where the NLR is ≥3.54, PE levels are <2%, and subjective symptoms are present, antibiotic treatment should be considered.

Loeffler's Syndrome Following Cutaneous Larva Migrans: An Uncommon Sequel

Cutaneous larva migrans (CLM) is characterized by the formation of distinctive, tortuous, and serpentine skin lesions occurring as a result of epidermal burrowing by certain helminthic larvae. Although this condition is usually uneventful, rarely it may result in patchy pulmonary infiltration with peripheral eosinophilia, also called Loeffler's syndrome. This association is fairly uncommon and is thus being reported.

The utility of inflammatory markers to predict readmissions and mortality in COPD cases with or without eosinophilia

BACKGROUND

COPD exacerbations requiring hospitalization increase morbidity and mortality. Although most COPD exacerbations are neutrophilic, approximately 10%-25% of exacerbations are eosinophilic.

AIM

We aimed to evaluate mortality and outcomes of eosinophilic and non-eosinophilic COPD exacerbations and identify new biomarkers that predict survival.

METHODS

A retrospective observational cohort study was carried out in a tertiary teaching hospital from January 1, 2014 to November 1, 2014. All COPD patients hospitalized with exacerbations were enrolled in the study at their initial hospitalization and followed-up for 6 months after discharge. Electronic data were collected from the hospital database. Subjects' characteristics, hemogram parameters, CRP levels, neutrophil-to-lymphocyte ratio (NLR), platelet-to-mean platelet volume ratio on admission and discharge, length of hospital stay (days), readmissions, and mortality were recorded. Patients were grouped according to peripheral blood eosinophil (PBE) levels: Group 1, >2% PBE, eosinophilic; Group 2, non-eosinophilic ≤2%. Patient survival after hospital discharge was evaluated by Kaplan-Meier survival analysis.

RESULTS

A total of 1,704 patients hospitalized with COPD exacerbation were included. Approximately 20% were classified as eosinophilic. Six-month mortality was similar in eosinophilic and non-eosinophilic groups (14.2% and 15.2%, respectively); however, the hospital stay length and readmission rate were longer and higher in the non-eosinophilic group (P<0.001 and P<0.01, respectively). CRP and NLR were significantly higher in the non-eosinophilic group (both P<0.01). The platelet-to-mean platelet volume ratio was not different between the two groups. Cox regression analysis showed that survival was negatively influenced by elevated CRP (P<0.035) and NLR (P<0.001) in the non-eosinophilic group.

CONCLUSION

Non-eosinophilic patients with COPD exacerbations with high CRP and NLR values had worse outcomes than eosinophilic patients. PBE and NLR can be helpful markers to guide treatment decisions.

Does eosinophilic COPD exacerbation have a better patient outcome than non-eosinophilic in the intensive care unit?

BACKGROUND

COPD exacerbations requiring intensive care unit (ICU) admission have a major impact on morbidity and mortality. Only 10%-25% of COPD exacerbations are eosinophilic.

AIM

To assess whether eosinophilic COPD exacerbations have better outcomes than non-eosinophilic COPD exacerbations in the ICU.

METHODS

This retrospective observational cohort study was conducted in a thoracic, surgery-level III respiratory ICU of a tertiary teaching hospital for chest diseases from 2013 to 2014. Subjects previously diagnosed with COPD and who were admitted to the ICU with acute respiratory failure were included. Data were collected electronically from the hospital database. Subjects' characteristics, complete blood count parameters, neutrophil to lymphocyte ratio (NLR), delta NLR (admission minus discharge), C-reactive protein (CRP) on admission to and discharge from ICU, length of ICU stay, and mortality were recorded. COPD subjects were grouped according to eosinophil levels (>2% or ≤2%) (group 1, eosinophilic; group 2, non-eosinophilic). These groups were compared with the recorded data.

RESULTS

Over the study period, 647 eligible COPD subjects were enrolled (62 [40.3% female] in group 1 and 585 [33.5% female] in group 2). Group 2 had significantly higher C-reactive protein, neutrophils, NLR, delta NLR, and hemoglobin, but a lower lymphocyte, monocyte, and platelet count than group 1, on admission to and discharge from the ICU. Median (interquartile range) length of ICU stay and mortality in the ICU in groups 1 and 2 were 4 days (2-7 days) vs 6 days (3-9 days) (P<0.002), and 12.9% vs 24.9% (P<0.034), respectively.

CONCLUSION

COPD exacerbations with acute respiratory failure requiring ICU admission had a better outcome with a peripheral eosinophil level >2%. NLR and peripheral eosinophilia may be helpful indicators for steroid and antibiotic management.

Peripheral eosinophilia and eosinophilic colitis during long-term azole therapy for pulmonary aspergillosis

Introduction:

Voriconazole and posaconazole are often used to treat invasive Aspergillus infections. We describe a patient with chronic pulmonary aspergillosis (CPA) who experienced peripheral eosinophilia and eosinophilic colitis while on voriconazole, and also experienced gastrointestinal symptoms and recurrent eosinophilia while on subsequent posaconazole therapy.

Case presentation:

A 75-year-old female with recurrent pulmonary mucus plugs due to CPA was treated with long-term oral voriconazole. The patient had no clinical evidence of CPA exacerbations while on such antifungal treatment but developed peripheral eosinophilia, diarrhoea and eosinophilic colitis after >5 years of voriconazole therapy that resolved after cessation of azole therapy. Due to a CPA exacerbation after stopping voriconazole, the patient was started on posaconazole as an alternative CPA therapy. However, after 15 months, the patient developed a recurrence of peripheral eosinophilia and diarrhoea while on posaconazole.

Conclusion:

Long-term use of voriconazole and posaconazole can be used successfully to reduce the incidence of CPA exacerbations. However, such antifungal therapy may also lead to peripheral eosinophilia, diarrhoea and eosinophilic colitis.

Clinical implications of initial peripheral eosinophilia in acute eosinophilic pneumonia

BACKGROUND AND OBJECTIVE

The initial peripheral eosinophil count (PEC) is rarely elevated but tends to increase during the clinical course of acute eosinophilic pneumonia (AEP). We evaluated whether initial peripheral eosinophilia is an indicator of mild disease in patients with AEP.

METHODS

We retrospectively examined associations between initial peripheral absolute eosinophil count, inflammatory markers and clinical characteristics in 85 patients with AEP.

RESULTS

Of 85 patients, 24 (28%) had initial peripheral eosinophilia (>500/μL). Initial peripheral absolute eosinophil count was inversely correlated to white blood cell (WBC) count (ρ = -0.386, P < 0.001), neutrophil percentage (ρ = -0.645, P < 0.001) and C-reactive protein (CRP; ρ = -0.495, P < 0.001). During treatment, peripheral absolute eosinophil counts increased, while inflammatory markers (WBC, neutrophil percentage, and CRP) decreased. Patients with initial peripheral eosinophilia had a longer duration from onset of symptoms to admission (P = 0.006), had lower WBC counts, neutrophil percentages and CRP values (all P < 0.001), and higher oxygen saturation (P = 0.004) than patients with normal peripheral eosinophil counts. Oxygen requirements (P = 0.013), duration of oxygen administration (P = 0.028) and intensive care unit admission rates (P = 0.003) were lower in patients with initial peripheral eosinophilia. All patients survived and recovered fully after corticosteroid or conservative treatment.

CONCLUSIONS

Initial PEC may be related to a milder disease status on admission, compared with normal PEC in patients with AEP. This may help to stratify disease severity in AEP.

Twenty two cases of canine neural angiostrongylosis in eastern Australia (2002-2005) and a review of the literature

Cases of canine neural angiostrongylosis (NA) with cerebrospinal fluid (CSF) evaluations in the peer-reviewed literature were tabulated. All cases were from Australia. A retrospective cohort of 59 dogs was contrasted with a series of 22 new cases where NA was diagnosed by the presence of both eosinophilic pleocytosis and anti-Angiostrongylus cantonensis immunloglobulins (IgG) in CSF, determined by ELISA or Western blot. Both cohorts were drawn from south east Queensland and Sydney. The retrospective cohort comprised mostly pups presented for hind limb weakness with hyperaesthesia, a mixture of upper motor neurone (UMN) and lower motor neurone (LMN) signs in the hind limbs and urinary incontinence. Signs were attributed to larval migration through peripheral nerves, nerve roots, spinal cord and brain associated with an ascending eosinophilic meningo-encephomyelitis. The contemporary cohort consisted of a mixture of pups, young adult and mature dogs, with a wider range of signs including (i) paraparesis/proprioceptive ataxia (ii) lumbar and tail base hyperaesthesia, (iii) multi-focal central nervous system dysfunction, or (iv) focal disease with neck pain, cranial neuropathy and altered mentation. Cases were seen throughout the year, most between April and July (inclusive). There was a preponderance of large breeds. Often littermates, or multiple animals from the same kennel, were affected simultaneously or sequentially. A presumptive diagnosis was based on consistent signs, proximity to rats, ingestion/chewing of slugs or snails and eosinophilic pleocytosis. NA was diagnosed by demonstrating anti-A. cantonensis IgG in CSF. Detecting anti-A. cantonensis IgG in serum was unhelpful because many normal dogs (20/21 pound dogs; 8/22 of a hospital population) had such antibodies, often at substantial titres. Most NA cases in the contemporary series (19/22) and many pups (16/38) in the retrospective cohort were managed successfully using high doses of prednisolone and opioids. Treatment often included antibiotics administered in case protozoan encephalomyelitis or translocated bacterial meningitis was present. Supportive measures included bladder care and physiotherapy. Several dogs were left with permanent neural deficits. Dogs are an important sentinel species for NA. Human cases and numerous cases in tawny frogmouths were reported from the same regions as affected dogs over the study period.

Eosinophilic esophagitis in Saudi children: symptoms, histology and endoscopy results

BACKGROUND/AIM

Eosinophilic esophagitis (EE) is a clinicopathologic entity characterized by esophageal symptoms in association with a dense eosinophilic infiltrate currently defined as >15 eosinophils per high power field in the appropriate clinical context. This is the first pediatric study in Saudi Arabia to give the experience with EE and examine its symptom, histology and endoscopy results.

MATERIALS AND METHODS

Retrospective chart review of all patients diagnosed with EE at National Guard Hospital, Jeddah Between 2007 and 2009. The authors identified EE on histologic criteria (≥15 eosinophils per high-power field) together with their clinical context. The authors reviewed medical records for details of clinical presentation, laboratory data, radiologic, endoscopic, and histologic findings, and the results of treatment.

RESULTS

We identified 15 patients in our database in the last three years. 100% of the patients were males. The median age at presentation was 10 years (range, 3-17 years). The commonly reported symptoms were failure to thrive (86%), epigastric abdominal pain (53%), poor eating (40%), dysphagia with solid food (26%), food impaction (13%), and vomiting (20%). Asthma was reported in 46% and allergic rhinitis in 40%. Peripheral eosinophilia (>0.7 Χ 10/l) was found in 66%. High serum IgE Level (>60 IU/ml) was found in 60%. Upper endoscopic analysis revealed esophageal trachealization in 46%, esophageal erythema in 46%, white specks on the esophageal mucosa in 33%, esophageal narrowing in 13%, and normal endoscopy in 13%. The mean eosinophils per high-power field was 30.4 (range, 20-71). Histologic characteristics included degranulated eosinophils (86%), basal cell hyperplasia (93%) and eosinophils clusters (micro-abscess) in 73%. The treatment of EE revealed that they used swallowed corticosteroid in 50%, proton pump inhibitors in 66%, elemental diet/ food elimination in 13% and systemic corticosteroid in 13%.

CONCLUSIONS

Failure to thrive and abdominal pain in a male, atopic school-aged child was the most common feature of EE. Peripheral eosinophilia, high serum IgE and endoscopic esophageal erythema and trachealization should significantly raise the clinical index of suspicion for the diagnosis of EE.