Case 41 – update 3

For the start of the case and the first and second updates scroll below (and also look at #teamhaem on Twitter for any relevant comments)…

Our patient has progressive eosinophilia of unknown cause (eosinophils 9.2×109/L (0-0.5)). He now has respiratory symptoms – with shortness of breath on exertion, cough with white sputum and on examination he has some fine expiratory crackles at the bases along with some pedal oedema. When he is exposed you also notice a rash which appears to be maculopapular. It is not overtly itchy and there is no urticaria/weals.  Is appetite has not been good. No diarrhoea.  There is no lymphadenopathy palpable although the spleen can be palpated 3 finger breaths below the costal margin.

A blood film is reported:

Progressive eosinophilia noted. The eosinophils are bilobed and appear normal in morphology. Lymphocytes are mostly small and mature and have a ‘benign’ appearance, but a clonal population cannot be ruled out by morphology alone. No left shift. No nucleated red cells or other signs of marrow infiltration. No Howell Jolly bodies. No dysplasia and monocytes appear with in normal limits. No excess of basophils seen. No evidence of parasitic infection. No primitive cells. Is there a known cause? Requires clinical correlation and consider review/discussion with haematology.

Remember the causes of eosinophilia are broadly categorised into three:

1) Primary haematological causes

2) Secondary/reactive cases including

  • Allergy/atopy
  • Medications
  • Infections
  • Malignancy
  • Autoimmune/vasculitis
  • Respiratory conditions

3) Idiopathic

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss) has been mentioned as has ‘eosinophillic pneumonia’. A CXR is outstanding.

Questions:

  • Can the differential diagnosis be narrowed?
  • How do you proceed with investigations now?
  • What are you worried about from the clinical history and examination?

Please reply to us (@TeamHaem) on Twitter and always include #TeamHaem to allow others to follow your comments. Please join in the debate and learn about haematological problems along the way. The case will continue to  evolve over the coming week so keep checking #TeamHaem on Twitter for more information.

Please note – all cases on TeamHaem are entirely fictional to protect patient confidentiality.

TeamHaem are not a position of authority.  It is an educational platform to allow discussion and learning.

About TeamHaem

Online education and discussion about all things haematological
This entry was posted in Laboratory morphology, Myeloproliferative neoplasm, Related to other specialities and tagged , , , . Bookmark the permalink.

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