THE TRAVELLER

Eosinophilia
William Newsholme
Tom Doherty

Eosinophilia is an increase in the total number of eosinophils in

the peripheral blood above 0.4 x 109/litre. The absolute count,
rather than a percentage, should be used to assess eosinophilia,
because the percentage relies on total WBC count rather than the
total number of eosinophils present. The eosinophil count varies
diurnally, being lowest at midday and highest at midnight.
In the context of tropical medicine, eosinophilia is suggestive,
but not diagnostic, of an underlying parasitic infection. Eosinophilia is almost never caused by protozoa (e.g. malaria, amoebiasis). Helminths are the major cause of parasite-related eosinophilia,
and the degree of eosinophilia is probably related to the extent of
tissue invasion and host exposure to helminth antigen.
Tapeworms and adult roundworms thus produce minimal, if
any, eosinophilia.
Larval migratory phases (e.g. Loefflers syndrome with Ascaris,
Katayama syndrome with schistosomiasis) and tissue helminths
(e.g. filariae, Toxocara) produce higher eosinophil counts.
Strongyloides migration almost invariably elicits eosinophilia,
but the eosinophil count is reduced during the hyperinfection
syndrome seen in immunocompromised individuals.
Not every patient with eosinophilia has a parasitic infection
(Figure 1), and the test has low sensitivity and a low positive
predictive value in both migrants and travellers. In particular,
many patients with atopy exhibit peripheral eosinophilia. If a pretravel full blood count is available, it may be useful in focusing
investigation on non-tropical causes. It must also be remembered
that symptoms may not be related to detected eosinophilia. This is
particularly the case in migrants, up to 80% of whom may harbour
asymptomatic intestinal helminth infections.

Diagnosis
To answer the question: Why did this patient, from this place,
develop these symptoms at this time?, a clear and detailed travel
history is necessary. This should address the destination to which
the individual travelled, when he travelled and for how long, and
what he did while he was away. For diagnostic purposes, it is also
important to consider when the last exposure occurred, to allow
for full maturation of the parasite (3 months for schistosomiasis,
6 months for filariasis).

William Newsholme is Specialist Registrar in Tropical and Infectious

Diseases at University College London Hospital, London, UK. Conflicts of
interest: none declared.
Tom Doherty is Consultant Physician at the Hospital for Tropical Diseases,
London, UK. Conflicts of interest: none declared.

MEDICINE 33:7

2005 The Medicine Publishing Company Ltd

THE TRAVELLER

Causes of eosinophilia

Laboratory investigations in eosinophilia

Tropical infections commonly associated with eosinophilia

Brugia malayi
Loaiasis
Mansonella perstans
Onchocerca volvulus
Strongyloidiasis
Toxocariasis
Wuchereria bancrofti
Tropical infections that may be associated with eosinophilia
Angiostrongylus
Ascaris lumbricoides
Cysticercosis
Dracunculiasis
Echinococcus
Fascioliasis
Gnathostomiasis
Hookworm
Paragonimiasis
Schistosomiasis
Trichinella
Trichuris trichiura
Non-tropical causes of eosinophilia
Allergic bronchopulmonary aspergillosis
Atopy
ChurgStrauss syndrome
Coccidioidomycosis
Drug allergy
Eosinophilic leukaemia
HIV and HTLV-1 infection
Hodgkins disease and other lymphomas
Hypereosinophilic syndrome
Inflammatory bowel disease
Pemphigoid
Pemphigus
Polyarteritis nodosa
Wegeners granulomatosis
Tropical infections not associated with eosinophilia
Amoebiasis
Arboviral infections
Brucellosis
Enteric fever
Giardia duodenalis
Leishmaniasis
Leprosy
Malaria
Trypanosomiasis

Stool microscopy for ova, cysts and parasites (repeated on

three occasions)
Day (Loa loa) and night (Wuchereria bancrofti, Brugia malayi)
blood samples for microfilariae
Terminal urine for Schistosoma haematobium ova
Skin snips for Onchocerca volvulus
Rectal snips for Schistosoma mansoni, Schistosoma japonicum
and Schistosoma haematobium
Depending on travel history, serological tests for
schistosomiasis, filariasis, strongyloidiasis, cysticercosis,
Echinococcus, Trichinella, fascioliasis, Toxocara
Upper gastrointestinal tract endoscopy with aspiration of
duodenal juice biopsy (for Strongyloides)
Sputum wet preparation for larval roundworms and
Paragonimus (if pulmonary symptoms)
Mazzotti test (for Onchocerca if skin snips negative)
Investigations must be tailored to the individual patient,
according to clinical features and travel history. Investigation by
multiple modalities improves the yield, particularly in infections
such as schistosomiasis and Strongyloides.
NB:

Diethylcarbamazine for Mazzotti test is currently not available

in the UK

Larva currens, an itchy, erythematous rash that moves quickly

(10 cm/hour) across the thorax or abdomen, is characteristic of
strongyloidiasis and tends to occur several years after infection.
Laboratory investigations are shown in Figure 2.

Management
Management depends on the results of investigations. The options
when all tests are negative are:
observation only
blind albendazole, 400 mg daily for 3 days (to cover intestinal
nematodes, particularly Strongyloides).

FURTHER READING
Harries A D, Myers B, Bhattacharrya D. Eosinophilia in Caucasians
returning from the tropics. Trans Roy Soc Trop Med Hyg 1986; 80:
3278.
Weller P F. Eosinophilia in the returned traveller. In: Armstrong D,
Cohen J, eds. Infectious diseases. London: Mosby, 2004.
Weller P F. Eosinophilia in travelers. Med Clin North Am 1992; 76:
141332.

Practice points

Eosinophilia should be defined in absolute terms

(> 0.4 x 109/litre) rather than as a percentage
Eosinophilia is suggestive, but not diagnostic, of parasitic
infection (usually helminthic)
A detailed travel and occupational history is essential
Patients with established parasitic infections may have normal
eosinophil counts

A patient who develops transient, recurrent, painful swelling of

the wrists months after travelling in rural West Africa is likely to
have Calabar swellings, which are highly suggestive of loaiasis.
A patient with a similar history who has returned from Asia is
more likely to have gnathostomiasis.
Cutaneous larva migrans caused by the dog hookworm occurs
soon after return from a beach holiday, often in the Caribbean.
MEDICINE 33:7

2005 The Medicine Publishing Company Ltd