Eosinophilia I

N.B. Some details have been changed.

A 22 year old man with a past medical history of mild asthma is transferred from an outside hospital for diagnostic evaluation. He was in his usual state of health until several months prior when he began having episodic fevers, chills, night sweats, headache, and myalgias. He couldn't identify any triggers but symptoms were more severe on the weekends.

He then had acute onset of global profound symmetric weakness of all extremities which prompted him to go to the emergency department. His neurologic exam was non-focal. A chest X-ray showed cardiomegaly and interstitial infiltrates, troponins were elevated with a peak of 15, and a transthoracic echocardiogram showed an ejection fraction of 50% with a pericardial effusion. At this time, he was found to have eosinophilia of 20%. He began having encephalopathy, and MRI showed bilateral scattered lesions consistent with embolic strokes. A CT abdomen, chest, pelvis showed prominent mediastinal lymph nodes, anasarca, and hepatomegaly.

He was diagnosed with and treated for myocarditis, but over his hospital course, began having a transaminitis with AST 1500, ALT 1200 as well as acute renal failure (Cr 1.5). At this point, with multiple strokes, myocardial injury, acute liver failure, and acute renal failure, he was transferred to our hospital. His lungs were doing well, but pulmonology was consulted to assess the possibility of transbronchial lymph node biopsy.

To fill in the rest of the history, he has mild asthma requiring occasional (once/week) use of an inhaler. He has a positive family history for lymphoma and lupus in second-degree relatives. He works with cleaning solvents, hunts wild game, had recent contact with bats, and has two pet lizards. He smokes, but denies drugs and alcohol.

On exam, he was afebrile with blood pressures 90s-100s/40s-60s, HR 80s-90s, breathing 12-18, saturating 95-100% on 2L nasal cannula. He was ill-appearing but not in acute distress. His neck was supple, he had bilateral bibasilar crackles, a hyperdynamic precordium, a soft belly, no palpable lymphadenopathy, trace edema, and altered mental status with global weakness but no focal deficits.

Chemistries were grossly normal with an improving creatinine. A CBC showed WBC 12, Hgb 12, Plts 100. Eosinophils were 2.4. INR was 1.5. Troponins were trending down. BNP was 600. AST/ALT were 200/400. U/A showed large Hgb, 21-50 RBC, 5-10 WBC, 30 prot. EKG was NSR, prolonged QT.

Wow. This was the first patient I saw when I came onto service, and it was a true Moffitt medicine mystery. More tomorrow.