Page 379 - Clinical Immunology_ Principles and Practice ( PDFDrive )

CHaPtEr 24 Eosinophils and Eosinophilia 359

the evolution of EGPA. Neurological, cutaneous, cardiac, and Immunological Disorders
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GI organ involvement is common. Cardiac involvement includes
pericarditis and small vessel cardiac vasculitis, and, much less CLINICaL PEarLS
commonly, endomyocardial thrombosis and fibrosis. Eosinophilia and Drug Reactions
Diverse drugs are capable of eliciting pulmonary eosinophilia.
More commonly implicated medications include nonsteroidal Drug reactions Examples
antiinflammatory drugs (NSAIDs) and antimicrobial medica- Interstitial nephritis Semisynthetic penicillins,
tions. Likewise, toxic agents, including those from occupational cephalosporins
exposure, can be responsible for pulmonary eosinophilia. Each of Pulmonary infiltrates Nitrofurantoin, sulfas, nonsteroidal
antiinflammatory drugs (NSAIDs)
these reactions has a defined etiological stimulus and hence differs Pleuropulmonary Dantrolene
from idiopathic and other eosinophilic diseases, but the clinical Hepatitis Semisynthetic penicillins, tetracyclines
presentation of drug- and toxin-elicited pulmonary eosinophilias Hypersensitivity vasculitis Allopurinol, phenytoin
can resemble other forms of pulmonary eosinophilia, including Asthma, nasal polyps Aspirin
acute or chronic eosinophilic pneumonia. Eosinophilia–myalgia L-Tryptophan contaminant syndrome
Asymptomatic Ampicillin, penicillins, cephalosporins
Skin and Subcutaneous Diseases Cytokine-mediated Granulocyte macrophage–colony-
stimulating factor (GM-CSF),
A number of cutaneous diseases can be associated with heightened interleukin (IL)-2
34
blood eosinophils, including atopic dermatitis, blistering dis- DRESS (drug reaction with Minocycline, allopurinol, anticonvulsants
orders including bullous pemphigoid, drug reactions, and two eosinophilia and systemic
diseases associated with pregnancy: (i) herpes gestationis and symptoms)
(ii) the syndrome of pruritic urticarial papules and plaques of Adapted from Weller PF. Eosinophilia and eosinophil-related
pregnancy. Eosinophilic pustular folliculitis is seen mostly in disorders. In: Adkinson NF, Jr., Yunginger JW, Busse WW, et al.,
patients with HIV infections and in those treated for hematological eds. Allergy: Principles and Practice, 6th ed. Philadelphia, Penn.:
malignancies or after bone marrow transplantation. In patients Mosby; 2003:1105.
with cutaneous involvement and eosinophilia, angiolymphoid
hyperplasia with eosinophilia and Kimura disease, eosinophilic
cellulitis (Wells syndrome), eosinophilic fasciitis, and eosinophilic Adverse reactions to medications are a common cause of eosino-
pustular folliculitis can be differentiated on the basis of histo- philia. Although often considered as hypersensitivity reactions,
pathology of biopsied lesions. Another syndrome, episodic in most instances of drug-associated eosinophilia, the mecha-
angioedema with eosinophilia, is characterized by recurring nism leading to eosinophilia is not understood. Eosinophilia
episodes of angioedema, urticaria, fever, and marked blood may develop without other manifestations of adverse drug reac-
eosinophilia. This syndrome responds to glucocorticosteroid tions, such as rashes or drug fevers. In addition, drug-induced
therapy. eosinophilia may be associated with distinct clinicopathological
patterns in which eosinophilia accompanies drug-induced
Gastrointestinal Diseases diseases that are characteristically limited to specific organs
EGIDs (Chapter 46), including eosinophilic esophagitis, eosino- with or without associated blood eosinophilia. When organ
philic gastroenteritis, and eosinophilic colitis, represent a het- dysfunction develops, cessation of drug administration is neces-
erogeneous collection of disorders in which there may be sary. Drug-induced interstitial nephritis may be accompanied by
eosinophilic infiltration of the mucosa, the muscle layer or the blood eosinophilia, and eosinophils may be detectable in urine.
serosa, the last of which can lead to eosinophilic ascites. Peripheral Unlike granulocyte–colony-stimulating factor (G-CSF) therapy,
blood eosinophilia may occur in EGIDs, although with eosino- therapy with GM-CSF can lead to prominent blood and tissue
philic esophagitis, peripheral blood eosinophil counts are often eosinophilia. Administration of IL-2 or of IL-2-stimulated lym-
normal. Eosinophils are present in the lesions of collagenous phocytes can be followed by the development of eosinophilia,
colitis and ulcerative colitis, but blood eosinophilia is usually most likely as a result of stimulated production of IL-5. Reac-
absent. GI eosinophilia elicited by intestinal helminths and tions to medications, often anticonvulsants, minocycline, and
eosinophilic enterocolitis as a result of hypersensitivity reactions allopurinol, can elicit DRESS (drug reaction with eosinophilia
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to medications must be excluded in patients with these diseases and systemic symptoms). In addition to cutaneous eruptions,
who have tissue eosinophilia. fever, lymphadenopathy, hepatitis, nephritis, atypical lympho-
cytosis, GI tract involvement, and eosinophilia are common
Rheumatological Disorders but variable elements of this drug-induced syndrome, which
Of the various forms of vasculitis, only two are commonly can be fatal. The triggering medication must be stopped, and
associated with eosinophilia. The principal eosinophil-related corticosteroids are often administered.
vasculitis is EGPA, formerly called Churg-Strauss syndrome (as Some primary immunodeficiency syndromes are associated
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discussed above; and in Chapter 58). Cutaneous necrotizing with eosinophilia. Hyper-IgE syndrome is characterized by
eosinophilic vasculitis with hypocomplementemia and eosino- recurrent staphylococcal abscesses of the skin, lungs, and other
philia is a distinct vasculitis of small dermal vessels that are sites; pruritic dermatitis; hyperimmunoglobulinemia E; and
extensively infiltrated with eosinophils. This form of vasculitis eosinophilia of blood, sputum, and tissues. Eosinophilia is
may occur in patients with connective tissue diseases. In addition, characteristic of Omenn syndrome, combined immunodeficiency
eosinophilia may uncommonly accompany rheumatoid arthritis with hypereosinophilia (Chapter 35).
itself but more commonly results from adverse reactions to Infiltration of eosinophils accompanies rejection of lung,
treatment medications (including NSAIDs, gold, and tetracyclines) kidney, and liver allografts. Tissue and blood eosinophilia occur
or concomitant vasculitis. early in the rejection process, and eosinophil counts and