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)…

To summarise – our patient has significant eosinophilia with a non-itchy maculopapular rash, splenomegaly and symptoms of heart failure. He has no peripheral lymhadenopathy. He has weight loss and anorexia. There is no diarrhoea or bleeding. A CXR shows some upper lobe diversion but no focal consolidation or hilar lymphadenopathy. Concerns about a vasculitic process such as eosinophilic granulomatosis with polyangiitis (Churg-Strauss) but ANCA are negative. A skin biopsy confirms an eosinophil infiltrate and no evidence of lymphoma. Urinalysis does not reveal proteinuria or haemoglobinuria.

Our patient is symptommatic from the eosinophilia.

Questions:

• What haematological causes of eosinophilia do you know? How would you investigate these?
• What empiric treatment may be needed pending further investigations?

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