Tropical pulmonary eosinophilia

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Tropical pulmonary eosinophilia (TPE, tropical eosinophilia, or Weingarten's syndrome), is characterized by cough, bronchospasm, wheezing, abdominal pain, and an enlarged spleen. Occurring most frequently in the Indian subcontinent and Southeast Asia, TPE is a clinical manifestation of lymphatic filariasis, a parasitic infection caused by filarial roundworms that inhabit the lymphatic vessels, lymph nodes, spleen, and bloodstream. Three species of filarial roundworms, all from the Onchocercidae family, cause human lymphatic filariasis: Wuchereria bancrofti , Brugia malayi , and Brugia timori . [1]

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Tropical pulmonary eosinophilia is a rare syndrome characterised by pulmonary interstitial infiltrates and marked peripheral eosinophilia. [2] This condition is more widely recognised and promptly diagnosed in filariasis-endemic regions, such as the Indian subcontinent, Africa, Asia and South America. In nonendemic countries, patients are commonly thought to have bronchial asthma. [3] [4] Chronic symptoms may delay the diagnosis by up to five years. [3] Early recognition and treatment with the antifilarial drug, diethylcarbamazine, is important, as delay before treatment may lead to progressive interstitial fibrosis and irreversible impairment. [5]

The condition of marked eosinophilia with pulmonary involvement was first termed tropical pulmonary eosinophilia in 1950. [6] The syndrome is caused by a distinct hypersensitive immunological reaction to microfilariae of W. bancrofti and Brugia malayi . [5] [7] However, only a small percentage (< 0.5%) [8] of the 130 million people globally who are infected with filariasis apparently develop this reaction. The clearance of rapidly opsonised microfilariae from the bloodstream results in a hypersensitive immunological process and abnormal recruitment of eosinophils, as reflected by extremely high IgE levels of over 1000 kU/L. [5] [9] The typical patient is a young adult man from the Indian subcontinent. [7]

Symptoms and signs

A persistent or recurrent cough that is aggravated at night, along with fatigue, weight loss and a low-grade fever in an individual who has lived or traveled in an area where filariasis is endemic suggests the diagnosis of this disease. Some people with this disease may also have enlarged lymph nodes in the neck, axillae or inguinal areas. Others may have a cough productive of bloody sputum and may also have a wheeze. [10]

Diagnosis

The diagnostic criteria for TPE include: [9]

High antifilarial IgG titers to microfilariae often result in cross reactivity with other nonfilarial helminth antigens, [11] [12] such as Strongyloides and Schistosoma antigens, as demonstrated in reported cases. It is important to exclude other parasitic infections before TPE is diagnosed, by serological tests, examination of stool specimens in a laboratory experienced in parasitic infections, or a trial of anthelmintic medication. Other parasitic infections, such as the zoonotic filariae, dirofilariasis, ascariasis, strongyloidiasis, visceral larva migrans and hookworm disease, may also be confused with TPE because of overlapping clinical features, serological profile and response to diethylcarbamazine. [5] [9] [12] [13] Radiological findings are nonspecific, with normal appearance on chest X-ray in up to 20% of patients. [7] Lung biopsy is not part of the routine diagnostic workup of tropical pulmonary eosinophilia. [2]

Treatment

The dramatic response to diethylcarbamazine, a commonly used drug for filariasis, almost confirms the diagnosis. No universal treatment guidelines have been established for tropical pulmonary eosinophilia. [3] The antifilarial diethylcarbamazine (6 mg/kg/day in three divided doses [2] for 21 days [8] remains the main therapeutic agent, and is generally well tolerated. Reported side effects include headache, fever, pruritus and gastrointestinal upset. [14] The eosinophil count often falls dramatically within 7–10 days of starting treatment. [2] [5]

See also

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<i>Wuchereria bancrofti</i> Species of parasitic worm

Wuchereria bancrofti is a filarial (arthropod-borne) nematode (roundworm) that is the major cause of lymphatic filariasis. It is one of the three parasitic worms, together with Brugia malayi and B. timori, that infect the lymphatic system to cause lymphatic filariasis. These filarial worms are spread by a variety of mosquito vector species. W. bancrofti is the most prevalent of the three and affects over 120 million people, primarily in Central Africa and the Nile delta, South and Central America, the tropical regions of Asia including southern China, and the Pacific islands. If left untreated, the infection can develop into lymphatic filariasis. In rare conditions, it also causes tropical pulmonary eosinophilia. No vaccine is commercially available, but high rates of cure have been achieved with various antifilarial regimens, and lymphatic filariasis is the target of the World Health Organization Global Program to Eliminate Lymphatic Filariasis with the aim to eradicate the disease as a public-health problem by 2020. However, this goal was not met by 2020.

<i>Brugia malayi</i> Medical condition

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<span class="mw-page-title-main">Lymphatic filariasis</span> Medical condition

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<span class="mw-page-title-main">Chyluria</span> Medical condition

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<i>Brugia</i> Genus of roundworms

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Lymphatic filariasis in India refers to the presence of the disease lymphatic filariasis in India and the social response to the disease. In India, 99% of infections come from a type of mosquito spreading a type of worm through a mosquito bite. The treatment plan provides 400 million people in India with medication to eliminate the parasite. About 50 million people in India were carrying the worm as of the early 2010s, which is 40% of all the cases in the world. In collaboration with other countries around the world, India is participating in a global effort to eradicate lymphatic filariasis. If the worm is eliminated from India then the disease could be permanently eradicated. In October 2019 the Union health minister Harsh Vardhan said that India's current plan is on schedule to eradicate filariasis by 2021.

References

  1. ↑ "CDC - Lymphatic Filariasis - Epidemiology & Risk Factors". 26 August 2021.
  2. 1 2 3 4 Yong, M.; Marshall, C.; Eisen, D. (2007). "Tropical pulmonary eosinophilia: A rare cause of cough in immigrants to Australia". The Medical Journal of Australia. 187 (7): 416–18. doi:10.5694/j.1326-5377.2007.tb01316.x. PMID   17908009. S2CID   28071413.
  3. 1 2 3 Boggild, A. K.; Keystone, J. S.; Kain, K. C. (2004). "Tropical Pulmonary Eosinophilia: A Case Series in a Setting of Nonendemicity". Clinical Infectious Diseases. 39 (8): 1123–28. doi: 10.1086/423964 . PMID   15486834.
  4. ↑ Jiva, T.; Israel, R.; Poe, R. (1996). "Tropical pulmonary eosinophilia masquerading as acute bronchial asthma". Respiration; International Review of Thoracic Diseases. 63 (1): 55–8. doi:10.1159/000196517. PMID   8833995.
  5. 1 2 3 4 5 Ong, R.; Doyle, R. (1998). "Tropical pulmonary eosinophilia". Chest. 113 (6): 1673–9. doi: 10.1378/chest.113.6.1673 . PMID   9631810.
  6. ↑ Ball, J. (1950). "Tropical pulmonary eosinophilia". Transactions of the Royal Society of Tropical Medicine and Hygiene. 44 (3): 237–58. doi:10.1016/0035-9203(50)90053-8. PMID   14809749.
  7. 1 2 3 Udwaida F. (1975). "Tropical eosinophilia". In Herzog H (ed.). Pulmonary eosinophilia: progress in respiration research. Basel, Switzerland: Karger. pp. 35–155.
  8. 1 2 "Lymphatic filariasis: The disease and its control. Fifth report of the WHO Expert Committee on Filariasis". World Health Organization Technical Report Series. 821: 1–71. 1992. PMID   1441569.
  9. 1 2 3 Ottesen, E. A.; Nutman, T. B. (1992). "Tropical Pulmonary Eosinophilia". Annual Review of Medicine. 43: 417–24. doi:10.1146/annurev.me.43.020192.002221. PMID   1580599.
  10. ↑ "Pulmonary Eosinophilia" . Retrieved 2011-04-16.
  11. ↑ Muck, A.; Pires, M.; Lammie, P. (2003). "Influence of infection with non-filarial helminths on the specificity of serological assays for antifilarial immunoglobulin G4". Transactions of the Royal Society of Tropical Medicine and Hygiene. 97 (1): 88–90. doi:10.1016/s0035-9203(03)90033-2. PMID   12886811.
  12. 1 2 Magnaval, J. -F.; Berry, A. (2005). "Tropical Pulmonary Eosinophilia". Clinical Infectious Diseases. 40 (4): 635–6. doi: 10.1086/427755 . PMID   15712096.
  13. ↑ Kuzucu, A. (2006). "Parasitic diseases of the respiratory tract". Current Opinion in Pulmonary Medicine. 12 (3): 212–21. doi:10.1097/01.mcp.0000219271.80804.9e. PMID   16582677. S2CID   21385631.
  14. ↑ McLaughlin, S.; Radday, J.; Michel, M.; Addiss, D.; Beach, M.; Lammie, P.; Lammie, J.; Rheingans, R.; Lafontant, J. (2003). "Frequency, severity, and costs of adverse reactions following mass treatment for lymphatic filariasis using diethylcarbamazine and albendazole in Leogane, Haiti, 2000". The American Journal of Tropical Medicine and Hygiene. 68 (5): 568–73. doi: 10.4269/ajtmh.2003.68.568 . PMID   12812348.
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