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Eosinophils matter:
Inspired by yesterday’s @CPSolvers case + last week’s NEJM case, reprising this thread with 5 more real case examples of this take-home point:
In acute presentations, eosinophilia is often a pivot point: it dramatically shifts/narrows the ddx.
1/11
Inspired by yesterday’s @CPSolvers case + last week’s NEJM case, reprising this thread with 5 more real case examples of this take-home point:
In acute presentations, eosinophilia is often a pivot point: it dramatically shifts/narrows the ddx.
1/11
Background: Glucocorticoids kill eosinophils. In acutely ill/stressed patients, the high endogenous cortisol should melt away your normal eos.
If you're acutely ill and have eosinophilia, the eos are probably related to why you're sick.
https://twitter.com/sargsyanz/status/1113043222283120641?s=20
2/
If you're acutely ill and have eosinophilia, the eos are probably related to why you're sick.
https://twitter.com/sargsyanz/status/1113043222283120641?s=20
2/
Background: it's absolute counts that matter. Eosinophilia is defined as AEC > 450.
Total WBC 2K with 15% eos? AEC is 300 (normal)
Total WBC 20K with 3% eos? AEC is 600 (elevated)
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Total WBC 2K with 15% eos? AEC is 300 (normal)
Total WBC 20K with 3% eos? AEC is 600 (elevated)
3/
Main eosinophilia causes: NAACP+1
Neoplasm: heme > solid
Allergy: drugs or atopy
Adrenal insuff: (loss of tonic suppression of eos)
Collagen-vascular dz: vasculitis, lupus
Parasites (helminths) & some fungi (cocci, aspergillus)
+ primary hypereo syndromes (eosin. X-itis)
4/
Neoplasm: heme > solid
Allergy: drugs or atopy
Adrenal insuff: (loss of tonic suppression of eos)
Collagen-vascular dz: vasculitis, lupus
Parasites (helminths) & some fungi (cocci, aspergillus)
+ primary hypereo syndromes (eosin. X-itis)
4/
All this summarized in excellent @CPSolvers schema.
Now on to brief summaries of 5 recent cases where eosinophilia changed everything.
5/ https://clinicalproblemsolving.com/dx-schema-eosinophilia/
Now on to brief summaries of 5 recent cases where eosinophilia changed everything.
5/ https://clinicalproblemsolving.com/dx-schema-eosinophilia/
Case A: a middle-aged woman with new heart failure.. pulmonary edema, runs of VT, borderline pressures.
Would have pursued only usual considerations and workup... but 700 eos in the blood.
Dx: eosinophilic myocarditis (needs steroids!)
6/
Would have pursued only usual considerations and workup... but 700 eos in the blood.
Dx: eosinophilic myocarditis (needs steroids!)
6/
Case B: Young man with severe pneumococcal pneumonia/empyema, initially in ICU, now improving on floor. Develops renal failure, fevers. No diff checked in a few days. 2200 blood eos.
Dx: drug hypersensitivity
Pearl: NEW onset eos while in hospital? Probably drugs
7/
Dx: drug hypersensitivity
Pearl: NEW onset eos while in hospital? Probably drugs
7/
Case C: Man sees PCP for dyspnea, diagnosed with COPD, given steroids.
Breathing initially better, but admitted to hospital with severe sepsis, blood growing GNRs. 500 eos.
Dx. disseminated strongyloidiasis
8/
Breathing initially better, but admitted to hospital with severe sepsis, blood growing GNRs. 500 eos.
Dx. disseminated strongyloidiasis
8/
Case D: Older guy admitted for rectal pain seemingly from bad hemorroids, and "lumbar strain, needing pain control/PT." He wasn't that sick, but 900 unexplained eos still expanded the differential and led to more aggressive eval.
Dx: rectal cancer with mets to spine
9/
Dx: rectal cancer with mets to spine
9/
Case E: Older Honduran woman with fevers, night sweats, and faint pulmonary opacities on CT. Infections were most highly considered, but blood 1100 eos..
Dx: eosinophilic granulomatosis with polyangiitis
10/
Dx: eosinophilic granulomatosis with polyangiitis
10/
Conclusion: Sometimes eosinophilia will be from a known, trivial, or unrelated cause like atopic disease.
But especially in acutely ill patients, it's often the key. Consider its differential, and how it may fit with the patient's presentation.
11/11
But especially in acutely ill patients, it's often the key. Consider its differential, and how it may fit with the patient's presentation.
11/11
