|Year : 2014 | Volume
| Issue : 2 | Page : 109-111
Eosinophilia in dermatological diseases: A study of one hundred patients
Ambika Harihara Subramony, Chankramath Sujatha, Pratyusha Kolanuvada
Department of Dermatology, MVJ Medical College and Research Hospital, Bangalore, Karnataka, India
|Date of Web Publication||9-Sep-2014|
Ambika Harihara Subramony
Department of Dermatology, MVJ Medical College and Research Hospital, B601, Sriram Shrishti Apartments, Sumangali Sevashram Road, Anand Nagar, Hebbal, Bangalore 560 032, Karnataka
Introduction: Eosinophils are multifunctional cells that play a characteristic role in various diseases of allergic and infective etiology. Eosinophils play an important role in immunity hence eosinophilia occurs in various diseases of skin and systemic allergic disorders. Materials and Methods: One hundred patients admitted to the Dermatology ward with absolute eosinophil count (AEC) above 500 cells per cubic millimeter were included in the study. Detailed history, including, drug history, travel history, history of atopy, and insect bites, was taken. A complete hemogram, stool examination, chest x-ray, and serological test were done to rule out eosinophilia due to other causes. Results: In our study, most of the patients (40%) were between the age group of 40 and 60 years. Fifty-six percent were male patients. Most of the patients (98%) fell in the category of mild-to-moderate eosinophilia. Marked eosinophilia was seen in only 2%. Most common skin conditions were chronic urticaria (28%) followed by generalized pruritus (16%), eczema (10%), drug reaction (10%), psoriasis (7%), bullous diseases (6%), palmoplantar keratoderma (4%), and HIV (4%). Malignancy was seen in 2%. Other conditions constituted 13%. Out of all these, 12% had stool examination positive for ova and cysts. Histopathological examination was done in 22 patients, 12 of whom showed tissue eosinophilia. Conclusion: Peripheral blood eosinophilia and/or infiltration of skin by eosinophils occur in various skin diseases. Coexisting parasitic infestations may be a predominant contributing factor for eosinophilia in tropical countries.
Keywords: Dermatological diseases, eosinophil, eosinophilia
|How to cite this article:|
Subramony AH, Sujatha C, Kolanuvada P. Eosinophilia in dermatological diseases: A study of one hundred patients. Trop J Med Res 2014;17:109-11
| Introduction|| |
Peripheral blood eosinophilia is a non-specific indicator of various diseases of allergic and infective etiology.  The major causes among them are parasitic infestations in developing countries, atopy, and various allergies in developed countries.  Various dermatological diseases of diverse etiology show both peripheral blood eosinophilia and tissue eosinophilia I of the skin. The aim of this study is to analyze various dermatological diseases with eosinophilia and to find other factors contributing to it.
| Materials and Methods|| |
One hundred patients admitted in the Dermatology Inpatient ward, with an absolute eosinophil count above 500 cell/cubic millimeter, from January 2012 to June 2013, were included in the study. A detailed history on drug intake, various allergies, atopy, insect bite reactions, and travel was taken. Routine blood for hemoglobin, total leucocyte count, differential count absolute eosinophil count, erythrocyte sedimentation rate, urine for albumin, sugar, and deposit for pus cells, and stool examination for ova and parasites were conducted on all patients. Various other radiological, biochemical, and serological tests and skin biopsy were undertaken, if found necessary. The patients were grouped according to the dermatological diagnosis made, based on the clinical findings and biopsy in some cases and absolute eosinophil count (AEC) into mild, moderate and severe eosinophilia [Table 1].
| Results|| |
Among the 100 patients, 64 patients were farmers, 22 patients were manual laborers, and 14 were students. Among the 100 patients, 56 were categorized as mild (AEC < 1000), 42 as having moderate eosinophilia (AEC 1000 to 1500), and only 2% showed marked eosinophilia, above 1500 cells/cubic millimeter. The most common condition was chronic urticaria in 28%, followed by generalized pruritus in 16%. Eczema and drug reactions were the diagnosis in 10% each. Four patients with drug reaction were diagnosed with drug reaction eosinophilia and systemic symptoms (DRESS) had moderate eosinophilia. Among the eczema cases, six patients had atopic eczema and four had contact dermatitis to Parthenium. Seven percent of the patients had psoriasis. Bullous diseases constituted 6%. Of the bullous diseases, four patients were diagnosed with bullous pemphigoid and had mild eosinophilia and two pemphigus patients had moderate eosinophilia. Four percent of the patients were positive for human immunodeficiency virus (HIV). Palmoplantar keratoderma was the diagnosis in 4%. Two percent with marked eosinophilia was diagnosed to have malignancy. One had Sézary syndrome and the other had Hodgkin's lymphoma. The remaining 13% were diagnosed with various other dermatological diseases.
Fourteen patients had stool positive for intestinal parasites. The remaining 13 patients with other skin diseases had mild eosinophilia. Fourteen patients showed tissue eosinophilia on skin biopsy, of whom, six were bullous diseases, four drug reactions, two malignancies, and two insect bite reactions.
| Discussion|| |
Eosinophils were first described by Paul Ehrlich, in 1879.  They form 1-5% of the peripheral leukocytes. As they play an important role in innate immunity they are also normally seen in the lymphoid organs, gastrointestinal tract (GIT), and lungs. The skin is devoid of eosinophils, except under pathological conditions.  The presence of tissue and blood eosinophilia in various dermatological diseases and signs and symptoms of these diseases can be attributed to the biological products released from the eosinophils. At one extreme their presence is transient and benign as in erythema toxicum neonatorum and incontinentia pigmenti,  and at the other extent it causes harmful tissue damage, as in the hypereosinophilic syndrome.
The mast cells release eosinophil chemotactic factors. The eosinophils are attracted to the sites of anaphylaxis, urticaria, angioedema, and atopy,  and they function as effector cells in various infections and infestations.  Diseases where antigen antibody deposition occurs, such as, in drug reactions and autoimmune bullous diseases like bullous pemphigoid, eosinophils are increased both in the blood and tissue. 
Malignant cells release interleukin 5, which attracts eosinophils, as shown by the elevated eosinophil count seen in various malignancies like Hodgkin's lymphoma and Sézary syndrome.  Very high eosinophilia in the blood, more that 1500 cells/cubicmillimeter, without any secondary etiology is called the hypereosinophilic syndrome (HES).  A very high eosinophil count also occurs as a primary eosinophilic malignancy, called 'clonal eosinophilia'.  A variety of tissues are damaged due to the release of eosinophilic mediators. The proteins released by eosinophils - MBP (major basic protein), ECP (eosinophilic cationic protein), and EPO (eosinophil peroxidase)  - are responsible for the severe edema observed in various eosinophilic conditions like the Wells syndrome  and Gleich syndrome.  Eosinophils, along with chemokines, release various fibroblast growth factors, which are responsible for the edema and fibrosis observed in eosinophilic fasciitis (Shulman syndrome),  toxic oil syndrome,  and the eosinophilia myalgia syndrome. Eosinophilic granules also have a procoagulent activity accounting for thrombotic episodes in HES. There are reports of increased platelet activity and eosinophil count in bullous pemphigoid. 
All drug reactions, particularly drug reaction eosinophilia and systemic symptoms (DRESS)  syndrome and eosinophilic polymorphic pruritic eruption associated with radiotherapy (EPPER) show a raised eosinophil count.  The Churg-Strauss syndrome (eosinophilia, asthma, systemic vasculitis, and lung infiltrates) is a type of granulomatous vasculitis, with tissue and blood eosinophilia.  Kimura's disease and angiolymphoid hyperplasia with eosinophilia are two other not so uncommon conditions showing skin and blood eosinophilia. 
Exclusion of secondary eosinophilia requires a careful review of the travel history, medication list, physical examination, and laboratory tests, including chest radiography, multiple stool ova, and parasite testing (hookworm, Schistosoma species), and serological tests for suspected pathogens (Strongyloides stercoralis, Schistosoma spp, Toxocara species, filarial worms). When a cause for secondary eosinophilia is not readily apparent, especially if it is severe eosinophilia, it is reasonable to make a working diagnosis of a clonal or idiopathic hypereosinophilic syndrome and investigate further to rule out malignancy.
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