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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 • • • • 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 • • • • • • 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