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Pawani N, Acharya S, Shukla S, Mahajan S. Idiopathic hypereosinophilic syndrome: A diagnostic challenge. Ann Trop Med Public Health 2014;7:193-4
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Pawani N, Acharya S, Shukla S, Mahajan S. Idiopathic hypereosinophilic syndrome: A diagnostic challenge. Ann Trop Med Public Health [serial online] 2014 [cited 2021 Jan 23];7:193-4. Available from: https://www.atmph.org/text.asp?2014/7/3/193/149507
A 45-year-old male, farmer, nonsmoker presented with complaints of cough with expectoration since 3-4 days and fever since 4 days. There was no history of dyspnoea, orthopnoea, palpitation, chest pain, hemoptysis, wheezing, rhinitis, skin rash and recent drug intake.
General and systemic examination was normal.
Investigations: Hb-13.0 g%, total lymphocyte count (TLC)-32100/cumm, differential leukocyte count (DLC): P-13%, L-28%, E-60%, M-02%, (significant eosinophilia), peripheral smear (PS): s/o eosinophilia, absolute eosinophil count (AEC)-19,260/cumm, [Figure 1] and [Figure 2].
|Figure 1: H and E stained slide under oil emersion fi eld (×100) showing eosinophilia
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|Figure 2: H and E stained slide under high power field (×40) showing eosinophilia
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Three days sputum sample for acid-fast bacilli-negative, chest X-ray – normal, high resolution computed tomography thorax: Normal. Bronchoscopy: Normal and bronchoalveolar lavage (BAL) fluid showed eosinophilia. There were no ascaris larvae in respiratory secretions and BAL fluid examination, three samples for stool examination on different days: Negative for ova, cysts. Serology test for strongyloides antibody was negative, ELISA for HIV: Negative, random blood sugar, liver function test, kidney function test: Normal, phosphatidylserine for microfilaria: Not detected, c-antineutrophil cytoplasmic antibodies: Negative, ultrasonography abdomen: Normal.
Repeat blood examination after 7 days; TLC-24,200/cumm, DLC: P-12%, L-16%, E-70%, M-2%, AEC-16,940/cumm. Possibility of idiopathic hypereosinophilic syndrome (IHES) was kept.
Patient was started with tablet prednisolone 40 mg/day after 5 days the counts were; TLC: 14,300/cumm, DLC: P-33%, L-20%, E-45%, M-2%, AEC-6435 per cumm.
Patient was discharged with Prednisolone 40 mg OD dose and were awaiting follow-up after 15 days.
Our patient presented with peripheral blood eosinophilia. The differential diagnosis of peripheral blood eosinophila and our approach to this case along with the way we tried to rule out the possibilities are highlighted in [Table 1]. As far as AEC are concerned, very high counts (>5,000/cumm) are usually associated with IHES. In our case, IHES was the diagnosis of exclusion, represented in [Table 1]. 
|Table 1: Differential diagnosis of eosinophilia and exclusion in our case
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Our patient presented for the first time in his life with eosinophilia. Majority of the potential conditions were ruled out. Though there was no evidence of any organ system involvement at this point of time. Hence, it is challenging to propose a definite diagnosis for patient’s eosinophilia. Initial stages of IHES may present like this. Patient is under close follow-up, so that the natural course of possibility of IHES may be ascertained later. ,
Seifert M, Gerth J, Gajda M, Pester F, Pfeifer R, Wolf G. Eosinophilia – A challenging differential diagnosis. Med Klin (Munich) 2008;103:591-7.
Klion AD, Bochner BS, Gleich GJ, Nutman TB, Rothenberg ME, Simon HU, et al. Approaches to the treatment of hypereosinophilic syndromes: A workshop summary report. J Allergy Clin Immunol 2006;117:1292-302.
Tefferi A, Patnaik MM, Pardanani A. Eosinophilia: Secondary, clonal and idiopathic. Br J Haematol 2006;133:468-92.
Gleich GJ, Leiferman KM. The hypereosinophilic syndromes: Current concepts and treatments. Br J Haematol 2009;145:271-85.
Bain BJ. Eosinophilia – Idiopathic or not? N Engl J Med 1999;341:1141-3.
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]