History

Fact Explanation
Presentation may vary from patient to patient This may be varied as there are several different types of pulmonary eosinophilia: simple pulmonary eosinophilia, chronic eosinophilic pneumonia, acute eosinophilic pneumonia, allergic bronchopulmonary aspergillosis and hypereosinophilic syndrome. [2]
Fever Fever is a presenting feature of pulmonary eosinophilia. [1,3] There will be eosinophilic infiltration of lung tissue leading to inflammation and release of pyrogens, that can cause fever.
Cough Cough is also a main presenting feature in pulmonary eosinophilia. [1] Inflammation of the bronchioles and alveoli causes production of mucus in the airways. Symptoms may mostly occur at night. [3]
Shortness of breath This may be due to impaired gas exchange and other complications of the disease such as pneumonia and respiratory failure. [1,3]
Involvement of the other organs When there is a systemic involvement, other organs of the body like skin, heart and nervous system can be affected. [2]
If complicated with respiratory failure This is one of the major complication of the disease. [1] Sometimes they can even develop chronic respiratory failure.
If complicated with pneumonia Patients may be having eosinophilic pneumonia. [1] Patient may looks ill, presents with acute onset yellowish sputum with high grade fever.
History of smoking Smoking makes the person vulnerable for complications pulmonary eosinophilia such as acute eosinophilic pneumonia. [1]
History of asthma and diffuse lung diseases Asthmatics [1] and patients with diffuse lung diseases are more vulnerable to get the pulmonary eosinophilia.
History of triggering factors Pulmonary eosinophilia can be associated with factors like drugs, parasites (Strongyloides, Ascaris, Toxocara, and Ancylostoma species) , fungal infection, mycobacterial infection, radiation and toxins. [2]
History of connective tissue diseases and malignancy Increased susceptibility for get the disease. [2]
History of fillariasis Tropical pulmonary eosinophilia is caused by parasites: Wuchereria bancrofti and Brugia malayi. These filarial parasites, are there in the lymphatics and release microfilariae from time to time, which then go to the pulmonary circulation. [3] Patient may be having features of filariasis; leg, scrotal or vulval swelling .
References
  1. KATZ U, SHOENFELD Y. Pulmonary eosinophilia. Clin Rev Allergy Immunol [online] 2008 Jun, 34(3):367-71 [viewed 26 June 2014] Available from: doi:10.1007/s12016-007-8053-y
  2. CAMPOS LE, PEREIRA LF. Pulmonary eosinophilia. J Bras Pneumol [online] 2009 Jun, 35(6):561-73 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19618037
  3. MULLERPATTAN JB, UDWADIA ZF, UDWADIA FE. Tropical pulmonary eosinophilia--a review. Indian J Med Res [online] 2013 Sep, 138(3):295-302 [viewed 27 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24135173

Examination

Fact Explanation
Febrile Fever may be a presenting feature. [1]
Clubbing Patients with aspergillosis will have clubbing due to bronchiectasis. [5]
Tachypnea Increased respiratory rate is seen with impaired gas exchange. [1]
Dyspnoea May one of the presenting sign. [1]
Rhonchi, Crepitations Wheezing may be associated with eosinophilic lung diseases specially with tropical pulmonary eosinophilia. [6] Crepitations can be associated in small number of patients. [3]
Signs of consolidation (reduced chest expansion, increased vocal fremitus , dull percussion note, coarse crepitations and bronchial breathing over theaffected area) If they are having chronic eosinophilic pneumonia [1] and lung fibrosis associated with bronchiectasis they can present with features of consolidation.
Signs of heart failure Involvement of the other organs [2] can be associated with pulmonary eosinophilia. Heart may be infiltrated with eosinophils.
Signs of pulmonary hypertension Pulmonary hypertension can develop in tropical pulmonary eosinophilia. [6] Clinical features include loud second heart sound and later features of right heart failure.
Leg, scrotal or vulval oedema Due to associated fillariasis in tropical pulmonary eosinophilia. [4]
References
  1. KATZ U, SHOENFELD Y. Pulmonary eosinophilia. Clin Rev Allergy Immunol [online] 2008 Jun, 34(3):367-71 [viewed 26 June 2014] Available from: doi:10.1007/s12016-007-8053-
  2. CAMPOS LE, PEREIRA LF. Pulmonary eosinophilia. J Bras Pneumol [online] 2009 Jun, 35(6):561-73 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19618037
  3. MULLERPATTAN JB, UDWADIA ZF, UDWADIA FE. Tropical pulmonary eosinophilia--a review. Indian J Med Res [online] 2013 Sep, 138(3):295-302 [viewed 27 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24135173
  4. CHITKARA RK, KRISHNA G. Parasitic pulmonary eosinophilia. Semin Respir Crit Care Med [online] 2006 Apr, 27(2):171-84 [viewed 26 June 2014] Available from: doi:10.1055/s-2006-939520
  5. CAPEWELL S, CHAPMAN BJ, ALEXANDER F, GREENING AP, CROMPTON GK. Corticosteroid treatment and prognosis in pulmonary eosinophilia. Thorax [online] 1989 Nov, 44(11):925-929 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC462149
  6. JINDAL SHIKHA, NATH ALOK, PATRA JEETENDERKUMAR, KUMAR SUDEEP. Tropical pulmonary eosinophilia presenting as severe pulmonary arterial hypertension. Ann Trop Med Public Health [online] 2013 December [viewed 27 June 2014] Available from: doi:10.4103/1755-6783.121001

Differential Diagnoses

Fact Explanation
Idiopathic Pulmonary fibrosis There is progressive fibrosis due to the proliferation of the fibroblasts in the lung parenchyma. They also can present the respiratory features like cough, shortness of breath and wheezing along with signs of consolidation. There will be diffuse pulmonary infiltrates on chest x-ray with associated fibrosis. [4]
Hypersensitivity pneumonitis This occur due to the exposure to various allergens, and they present with respiratory symptoms such as cough , shortness of breath and wheezing. Sometimes they also can develop systemic features like fever and weight loss. [3] Blood allergen specific antibody level may be elevated. It may present as acute, subacute or chronic form.
Visceral larva migrans Clinical features of visceral larva migrans would be due to allergic reaction of the host and it will give rise to lung and systemic symptoms. [1] There may be persistent eosinophilia in these patients.
Dirofilariasis This is a rare zoonotic infection due to by dog parasite- Dirofilaria. Mostly affected ones are asymptomatic. But sometimes they can develop serious complications of the lungs and cardiovascular system. [2] There can be pleural effusions and heart failure.
Bronchial asthma Bronchial asthma is one of the differential diagnosis for pulmonary eosinophilia. [5] Aathmatics may present with same clinical features especially wheezing. But they will have a clear history triggering factors such as dust, mites, smoke, respiratory tract infections etc.
References
  1. MORIMATSU Y, AKAO N, AKIYOSHI H, KAWAZU T, OKABE Y, AIZAWA H. A familial case of visceral larva migrans after ingestion of raw chicken livers: appearance of specific antibody in bronchoalveolar lavage fluid of the patients. Am J Trop Med Hyg [online] 2006 Aug, 75(2):303-6 [viewed 27 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16896137
  2. SIMóN F, SILES-LUCAS M, MORCHóN R, GONZáLEZ-MIGUEL J, MELLADO I, CARRETóN E, MONTOYA-ALONSO JA. Human and animal dirofilariasis: the emergence of a zoonotic mosaic. Clin Microbiol Rev [online] 2012 Jul, 25(3):507-44 [viewed 27 June 2014] Available from: doi:10.1128/CMR.00012-12
  3. LACASSE YVES, GIRARD MéLISSA, CORMIER YVON. Recent Advances in Hypersensitivity Pneumonitis. Chest [online] 2012 July [viewed 27 June 2014] Available from: doi:10.1378/chest.11-2479
  4. GROSS THOMAS J., HUNNINGHAKE GARY W.. Idiopathic Pulmonary Fibrosis. N Engl J Med [online] 2001 August, 345(7):517-525 [viewed 27 June 2014] Available from: doi:10.1056/NEJMra003200
  5. MULLERPATTAN JB, UDWADIA ZF, UDWADIA FE. Tropical pulmonary eosinophilia--a review. Indian J Med Res [online] 2013 Sep, 138(3):295-302 [viewed 27 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24135173

Investigations - for Diagnosis

Fact Explanation
Blood eosinophil count There may be high eosinophil count in the peripheral blood. [1] Studies have defined it as >500*106/L. [2] Sometimes eosinophil count can go down during the night especially in tropical pulmonary eosinophilia. [5]
IgE level Serum IgE level may be elevated. [2] In tropical pulmonary eosinophilia, there may be specific IgE to filarial antigens. [5]
Chest x-ray Reticulonodular pulmonary infiltrates are seen in the chest x-ray film. [1,4]
Bronchoalveolar larvage Bronchoalveolar fluid contains increased number of eosinophils. [1]
Lung biopsy This is used only if the clinical and radiological evidence are inconclusive. This will show pulmonary infiltrates consists of eosinophils, macrophages, lymphocytes and neutrophils. [3]
Full blood count This shows leucocytosis. [4]
Erythrocyte sedimentation rate As there is inflammation, ESR can be increased. [5]
References
  1. KATZ U, SHOENFELD Y. Pulmonary eosinophilia. Clin Rev Allergy Immunol [online] 2008 Jun, 34(3):367-71 [viewed 27 June 2014] Available from: doi:10.1007/s12016-007-8053-y
  2. CAPEWELL S, CHAPMAN BJ, ALEXANDER F, GREENING AP, CROMPTON GK. Corticosteroid treatment and prognosis in pulmonary eosinophilia. Thorax [online] 1989 Nov, 44(11):925-929 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC462149
  3. CAMPOS LE, PEREIRA LF. Pulmonary eosinophilia. J Bras Pneumol [online] 2009 Jun, 35(6):561-73 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19618037
  4. JINDAL SHIKHA, NATH ALOK, PATRA JEETENDERKUMAR, KUMAR SUDEEP. Tropical pulmonary eosinophilia presenting as severe pulmonary arterial hypertension. Ann Trop Med Public Health [online] 2013 December [viewed 27 June 2014] Available from: doi:10.4103/1755-6783.121001
  5. MULLERPATTAN JB, UDWADIA ZF, UDWADIA FE. Tropical pulmonary eosinophilia--a review. Indian J Med Res [online] 2013 Sep, 138(3):295-302 [viewed 27 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24135173

Investigations - Fitness for Management

Fact Explanation
Pulmonary function tests and diffusing capacity Lung functions ( Forced expiratory volume in first second-FEV1 and vital capacity-VC ) [1] and diffusing capacity may be reduced. Pulmonary functions show restrictive changes [2] and are severely affected in aspergillosis. [1]
References
  1. NESARAJAH MS. Pulmonary function in tropical eosinophilia before and after treatment with diethylcarbamazine. Thorax [online] 1975 Oct, 30(5):574-577 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC470330
  2. MULLERPATTAN JB, UDWADIA ZF, UDWADIA FE. Tropical pulmonary eosinophilia--a review. Indian J Med Res [online] 2013 Sep, 138(3):295-302 [viewed 27 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24135173

Investigations - Followup

Fact Explanation
Blood eosinophil count Get reduced with the treatment. [1]
Chest x-ray Radiographic infiltrates are get resolved with the corticosteroid treatment. [1,2]
Lung functions Total lung capacity, vital capacity, forced expiratory volume in first second and peak expiratory flow rate, are improving with nthe treatment. [1] improved
Erythrocyte sedimentation rate This will be returning to normal. [3]
Filaria complement fixation test Will be negative after treatment in tropical pulmonary eosinophilia. [3]
References
  1. CAPEWELL S, CHAPMAN BJ, ALEXANDER F, GREENING AP, CROMPTON GK. Corticosteroid treatment and prognosis in pulmonary eosinophilia. Thorax [online] 1989 Nov, 44(11):925-929 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC462149
  2. NESARAJAH MS. Pulmonary function in tropical eosinophilia before and after treatment with diethylcarbamazine. Thorax [online] 1975 Oct, 30(5):574-577 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC470330
  3. NESARAJAH MS. Pulmonary function in tropical eosinophilia before and after treatment with diethylcarbamazine. Thorax [online] 1975 Oct, 30(5):574-577 [viewed 27 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC470330

Investigations - Screening/Staging

Fact Explanation
Pulse oximetry Hypoxia can occur during the acute attacks specially with the development of complications such as pneumonia. [1]
Echocardiogram Heart can be affected in eosinophilic infiltration [2] and there can be ventricular failure.
References
  1. KATZ U, SHOENFELD Y. Pulmonary eosinophilia. Clin Rev Allergy Immunol [online] 2008 Jun, 34(3):367-71 [viewed 26 June 2014] Available from: doi:10.1007/s12016-007-8053-
  2. CAMPOS LE, PEREIRA LF. Pulmonary eosinophilia. J Bras Pneumol [online] 2009 Jun, 35(6):561-73 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19618037

Management - General Measures

Fact Explanation
Avoidance of the triggering factor This is an important measure in prevention. [1]
Respiratory support Patients with eosinophilic pneumonia readily can go into the respiratory failure. May be needed in dyspnea and respiratory failure. [1]
Prevention In tropical pulmonary eosinophilia, the parasite gets transmitted via a mosquito. Preventing mosquito bites is important in reducing the incidence of the disease. [2]
Management of relapses Tropical pulmonary eosinophilia can have relapses and treatment with diethylcarbamazine is recommended. [2]
References
  1. KATZ U, SHOENFELD Y. Pulmonary eosinophilia. Clin Rev Allergy Immunol [online] 2008 Jun, 34(3):367-71 [viewed 26 June 2014] Available from: doi:10.1007/s12016-007-8053-y
  2. MULLERPATTAN JB, UDWADIA ZF, UDWADIA FE. Tropical pulmonary eosinophilia--a review. Indian J Med Res [online] 2013 Sep, 138(3):295-302 [viewed 27 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24135173

Management - Specific Treatments

Fact Explanation
Diethylcarbamazine This is a oral drug used in tropical pulmonary eosinophilia. Symptomatic relief is observed within few days of treatment. Usual daily dose is 8mg/kg.[1] This is usually recommended for 3 weeks duration. [3] Side effects are nausea and vomiting and these are not frequent. [1]
Corticosteroids These are used in some occasions depend on the aetiology and severity of the symptoms. Corticosteroids are important to clear the pulmonary infiltrates on chest x-ray and to bring down the eosinophilia in blood. Prednisolone reduces the inflammation, thus the damage to the lung tissue. [3] Long Term steroids can be used to prevent lung damage. [2]
References
  1. SHANKER A, BHARGAVA RK, SHRIVASTAVA BN. Diethylcarbamazine in Tropical Pulmonary Eosinophilia Br Med J [online] 1960 Jan 9, 1(5166):100-103 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1966202
  2. CAPEWELL S, CHAPMAN BJ, ALEXANDER F, GREENING AP, CROMPTON GK. Corticosteroid treatment and prognosis in pulmonary eosinophilia. Thorax [online] 1989 Nov, 44(11):925-929 [viewed 26 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC462149
  3. JINDAL SHIKHA, NATH ALOK, PATRA JEETENDERKUMAR, KUMAR SUDEEP. Tropical pulmonary eosinophilia presenting as severe pulmonary arterial hypertension. Ann Trop Med Public Health [online] 2013 December [viewed 27 June 2014] Available from: doi:10.4103/1755-6783.121001