Transcript Eosinophilia - Camden GP Website

Eosinophilia
Mike Brown
Hospital for Tropical Diseases,
UCLH
[email protected]
• 19 year old Caucasian man
• fever
cough
lethargy
headache
3 days
1 day
• returned from “African trip” 3 weeks ago
– Swam in Lake Malawi one month before
presentation
70% risk of becoming seropositive for schistosomiasis after
swimming for 1 day at Cape Maclear
Lancet 1996
Full Blood Count
• Hb
13.9
• WCC 8.1
(13.5 - 17 g/dl)
(3.0 - 10.0 x 109/l)
– eosinophils 0.8 (<0.4 x 109/l)
• Pl
200
(150 - 400 x 109/l)
Acute Schistosomiasis
Katayama Fever
• Swam in Lake Malawi one month ago
• fever, lethargy, cough
• eosinophilia
0.8 at presentation
6.7 1/52 later
• abnormal LFT’s
– ALT peak 415 U/l day 5
– ALP peak 146 U/l day 5
Diagnostic Investigations
• Terminal urine for S. haematobium
urinalysis
trace blood
• Stool OCP x 3 for S. mansoni
• Schistosoma serology
– ELISA
– not always positive at time of presentation
– in this case positive at level 5
TREATMENT
• STEROIDS
– Prednisolone 30 mg od for 3 days
• PRAZIQUANTEL
– kills adult worms only
– will need repeated 3 months following
last exposure
– 40 mg/kg in 2 divided doses
Acute schistosomiasis
• Logan et al 2013
• 79 cases presenting to HTD
• 50% Lake Malawi
• Symptoms
– fever
– cough
– rash
>70%
>60%
35%
Symptomatic worm disease in travellers
Cutaneous larva migrans
Neuroschistosomiasis
Loa Loa
Strongyloidiasis
Symptomatic worm disease in
heavily exposed migrants
Hydatid disease
Neurocysticercosis
Lymphatic filariasis
Potential outcome of untreated
asymptomatic Strongyloides
severe diarrhoea, bowel obstruction, gram negative sepsis in patients
receiving steroids or chemotherapy – even 40 years after exposure!
Eosinophilia
• Worm infection found in ~50% travellers
investigated.
• Often the only manifestation of worm infection
• Important to exclude some infections therefore
investigation is justified.
• Need a strategy for appropriate investigations
Asymptomatic eosinophilia
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Strongyloides
Schistosoma
Filaria
- consequences if undiagnosed
• [Hookworm, ascaris, trichuris]
• Non-parasitic causes
Eosinophilia and progression to active tuberculosis:
- do worms cause TB reactivation?
Kaplan-Meier survival estimates, by eosinophil count (x109/l)
1
<0.400
proportion
free of
.9
>=0.400
tuberculosis
.8
.7
0
1
years
2
Adjusted rate ratio 2.54, p=0.007
Elliott et al 2003
3
Non-parasitic causes
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•
Atopy & allergic drug reactions
Allergic broncho-pulmonary aspergillosis
Churg-Strauss syndrome
Sarcoidosis
Leukaemia & lymphoma
Hypereosinophilic syndromes
Investigations:
• Stool microscopy -“ova, cysts & parasites”
• Strongyloides culture
• Terminal urine (S. haematobium)
• Day & Night bloods - Loa loa
for microfilariae
- Lymphatic filariasis
• Skin snips
- Onchocerciasis
• Serology
- Filaria, schistosoma
strongyloides etc.
Diagnoses in those with eosinophilia
Whetham et al 2003
Which tests do I do?
Scanned image of HTD
parasitology request
form
Investigation of a raised absolute eosinophil count
Basic package for all areas:
• Stool microscopy - “ova, cysts & parasites”
• Strongyloides serology [& stool culture]
Africa:
Plus:
• terminal urine microscopy
• Schistosoma serology
• [Filarial serology]
~29/30 cases
diagnosed on
1st visit
Strongyloides & GI symptoms
• Abdominal bloating
• Epigastric pain
• Diarrhoea
-often mild, sometimes more severe.
Evidence unclear on relationship between GI sx and
strongyloides infection
Infectious Diseases SpR in general GI OPD
Oct 04-Sept 05
8 immigrants from Africa/Asia with eosinophilia
→ 5 Strongyloides serology positive
Rx ivermectin 200mg/kg stat dose
?resolution of eosinophilia ?symptoms.
40% migrants with eosinophilia had
helminth infections – with resolution
of eos & symptoms after treatment
Strongyloides in E London
? Prevalence in migrants (>70% in SE Asians in Canada)
Strongyloides in E London
– a primary care study
• What is prevalence of Strongyloides among
Bangladeshi migrants in London?
• Does eosinophilia have predictive value for
Strongyloides in this setting?
• Is infection associated with GI morbidity?
o
• and so reduce referrals to 2 care
Preliminary Results
Positive
Eosinophilia
33%
GI symptoms
18%
FBC controls
15%
…no clear association with GI sx, but reported
sx resolution after treatment [Placebo?]
Summary
Look at the absolute eosinophil count
Investigate if migrant or traveller
- it may explain their symptoms, or cause problems later
Refer, or do basic tests:
Stool (+ urine) microscopy, Strongyloides ~/- schistosoma serology