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A 63-year-old male farmer presented marked eosinophilia. He had no symptoms of fever, night sweats or weight loss and no signs of anaemia, jaundice or lymphadenopathy. The leucocyte count was 17.27×109/l, with 53.1% eosinophils, but no eggs or parasites were found in his faeces. Blood chemistry results were within normal limits except for an elevated alanine aminotransferase level of 77 U/l. Serum total immunoglobulin E (IgE) was high at 340 kU/l. Specific IgG antibodies to Taenia solium, Paragonimus westermani, Sparganum mansoni and Clonorchis sinensis were negative. The patient’s first absolute eosinophil count during his hospitalisation was 27.25×109/l. Both a chest CT scan and an echocardiograph were normal. A contrast-enhanced CT scan of the liver showed multiple, small, ill-defined, round, low-attenuating nodules with hepatomegaly. There was no evidence of lymphadenopathy on both a chest and abdominal CT scan. Bone marrow specimens revealed normocellular marrow with marked eosinophilia and no evidence of eosinophilic leukaemia. His eosinophils had increased to 46.32×109/l, so he was treated with prednisolone at 1 mg/kg/day. The pronounced eosinophilia improved and he was discharged. We tapered the dose of prednisolone to 0.8 mg/kg/day over 3 months and his eosinophil counts returned to normal at 0.02×109/l.
Four months later, he was admitted again with dyspnoea on exertion and hypoxaemia. The lower lungs exhibited fine bilateral crackles. The leucocyte count was 13.39×109/l with 0.7% eosinophils (0.10×109/l). A chest radiograph showed peripheral reticulonodular opacities in both lungs. A high-resolution CT showed fine reticulation and irregular linear opacity with predominant subpleural distribution (fig 1). Pulmonary function tests showed a reduction in diffusing capacity (55% predicted).
What questions might you ask the farmer?
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Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.