Dr Rajesh SwarnakarMD,DTCD,DNB,FCCP(USA)

Consultant Pulmonologist &Director

Getwell Hospital & Research Institute, NAGPUR

Raised Eosinophill Count :

Clinical Significance

•

--Two-lobed, polymorphonuclear leukocyteTwo-lobed, polymorphonuclear leukocyte 12 to 15 um diameter 12 to 15 um diameter

- Created by IL-3, Il-5 and GM-CSF - Created by IL-3, Il-5 and GM-CSF -Three granule types, largest made up of MBP (major -Three granule types, largest made up of MBP (major basic protein)basic protein)

- Kills Parasites, tumor cells, - Kills Parasites, tumor cells, -Circulates <18 hours-Circulates <18 hours- 100-400 x more in tissues than in blood- 100-400 x more in tissues than in blood

Eosinophil – our friend or foe ?

Can happen in Blood&TissueCan happen in Blood&Tissue

• Bronchoscopy (BAL) EOS Percentage (%) rather than absolute number

Normal volunteers = < 1%

Raised Eosinophill Count:

•Blood Eosinophillia : Sampling peripheral blood

•Pulmonary Eosinophillia:Measured in BAL

Eosinophils count: What’s Normal?

•Blood EOS (#) = up to 600/cmm

Eosinophil – associated diseases and disorders

The degree of Blood eosinophilia can be categorized into :

Mild 500 to 1500 cells/microL

Moderate 1500 to 5000 cells/microL

Severe >5000 cells/microLCategories of Eosinophilia

Peripheral eosinophilia can be divided into categories of ,

primary, secondary, or idiopathic eosinophilia

Eosinophils can also be seen in Hodgkin's and non Hodgkin lymphoma and other metastatic cancers, but the associated eosinophils are not of a clonal nature in this situation

Primary eosinophilia

Usually occurs in the context of hematologic malignancies, such as acute leukemias or chronic myeloid disorders, when there is evidence of clonal expansion of eosinophils

The most common cause for secondary eosinophilia :

is parasitic lung infection. Noninfectious causes of secondary eosinophilia include allergic disorders, medications, toxins, autoimmune diseases, and endocrine disorders such as Addison's disease.

A diagnosis of idiopathic eosinophilia is considered when a thorough evaluation does not identify either a primary or secondary cause of eosinophilia

Diseases Associated with Blood & Diseases Associated with Blood & Pulmonary EosinophiliaPulmonary Eosinophilia

•Pulmonary Eosinophilic Syndromes of Known Cause:

Parasitic-induced eosinophilic pneumonias (including Loeffler’s syndrome) Drug-or toxin-induced eosinophilic pneumonias Tropical pulmonary eosinophilia Allergic bronchopulmonary mycosis.

•Pulmonary Eosinophilic Syndromes of Unknown Cause:

Idiopathic acute eosinophilic pneumonia Chronic eosinophilic pneumonia Churg-Strauss syndrome (allergic granulomatosis and angiitis) Idiopathic hypereosinophilic syndrome

Interstitial lung disease -Idiopathic pulmonary fibrosis -Collagen-vascular disease associated -Sarcoidosis -Eosinophilic granuloma (pulmonary histiocytosis X) Malignancy -Non–small-cell cancer of lung -Non-Hodgkin’s lymphoma -Myeloblastic leukemia Miscellaneous (e.g., lung transplantation, ulcerative colitis

Treatment of primary disease suffices to bring down raised eosinophil count.

Bronchocentric granulomatosis Bronchiolitis obliterans-organizing pneumonia Infections – Fungal (esp.Coccidioidomycosis, Aspergillus,Pneumocystis jirovecii) -Tuberculosis

Other Lung Diseases Variably Associated with Eosinophilia:Asthma/allergy

Algorithmic approach to evaluation patients with pulmonary/blood eosinophillia :

( Am J Respir Crit Care Med 150:1423-138,1994.)

History & Physical Exam

Collagen Vascular DiseaseHIV RisksDrugsAsthma HistoryTravel History

Stool Ova & Parasite ExamStrongyloidesAscaris SchistosomaAncylosioma

Pulmonary Function Tests

Obstruction

Non- PulmonaryOrgan Involvement

Pulmonary Involvement Only

Churg-Strauss Chest x-ray NormalIgE < 1.000

Chest x-ray Abnormal IgE > 2.000

Asthma

Allergic Bronchopulmonary Aspergillosis Bronchocentric Granulomatosis

Restriction

Bronchoalveolar Lavage

PneumocystisStrongyloidesAspergillusCryptococcus

> 20% Eosinophils < 20% Eosinophils

Blood Eosinophil Count Interstitial Lung DiseaseDrug Reaction

High Moderate Low/Normal

Hypereosinophilic Syndrome

Chronic Eosinophilic Pneumonia Simple Pulmonary Eosinophilia

Acute Eosinophilic Pneumonia

CEP ABPA CSS HIS

Subacute Acute, subacute, chronic Acute, subacute, chronic Subacute, chronic

+ (30 – 60 %) Nearly 100% 100% -

Mild – mod. In most Typical Extreme, fluctuating Extreme, persistent

Striking In some Prominent Striking

Mod. –elev. In 30% Marketed elev. , fluctuates w/disease

Mod. –elev. Mod. –elev. In some

Unknown Aspergillus (or other fungus) Unknown Unknown

Predominately, peripheral consolidation and GGOs “photographic negative of pulmonary edema”

Upper lobe predominant proximal bronchiectasis

Transient. Migratory peripheral, rarely diffuse: patchy peribronchial and septal thickening, patchy parenchymal GGO or consolidation

Transient, focal or diffuse

Normal. OVD, or RVD OVD +/- RVD OVD +/- RVD Mild RVD in some

None See Table 72 – 4 Histopathology plus appropriate clinical setting

Extreme persistent eosinophilia and multi-organ dysfunction (no other evident cause)

Occasionally mild, non –necrotic

None Characteristic (see text) None

Very rare reported None Typical of vasculitic phase Cardiac, neurological. GI, hematological, other

Corticosteroids Corticosteroids, bronchodilators, antibiotics, antifungals

Corticosteroids, other immunosuppressive (see text)

Corticosteroids, other immunosuppressive (see text)

Common Typical Infrequent after Rx Chronicity typical

Thank you for your Kind Thank you for your Kind attentionattention

This presentation is available on www.lungscare.com/ppt Email :

drrajeshswarnakar@gmail.com

1st -2nd February, 2014Hotel Hyatt Regency, Pune, India

International Conference on Insights and Management of COPD

On behalf of the organising committee, it gives us immense pleasure to welcome you to the first international conference on COPD – ICONIC 2014, to be held on 1st and 2nd February, 2014 at “Hotel Hyatt Regency”, Pune.

The scientific programme will cover insights on the burden, pathophysiology, risk factors for COPD, advances in disease management and new directions for research in COPD, and a discussion on the much needed policy change in the management of COPD practices in India.

Come listen to some of the internationally acclaimed leaders in Respiratory Medicine from across the globe including Prof. P. J. Barnes, Prof. James Hogg, Dr. John Walsh, Dr. Robert A. Wise, Dr. Sonia Buist, Dr. John R. Balmes and others.

Once again we extend a cordial welcome to you all and look forward to your active participation in ICONIC – 2014!!!

Dear friends and colleagues,

Organizing committee office:Chest Research Foundation, Kalyani Nagar, Pune 411014, INDIA

Secretariat contact: Telephone (Contact): +91 22 2494 0518 Fax: +91 22 2494 0517 Email: secretariat@iconic2014.com Website: : www.iconic2014.com

ICONIC - 2014

Organized by: Chest Research Foundation, India and Johns Hopkins University, USA

ICONIC is Endorsed by: