Workup for eosinophilia

With automated differentials being a common part of routine blood counts, the finding of eosinophilia is a relatively frequent occurrence. The first step in elucidating the cause is to determine the absolute eosinophil count (AEC), which is calculated from multiplying the percentage of eosinophils by the total white blood cell count. Eosinophilia is defined as an AEC of >500 eosinophils/μL, whereas hypereosinophilia is defined as an AEC of ≥1500 eosinophils/μL, a separation that is useful as an initial approach to the evaluation of such patients. Peripheral blood eosinophilia is most commonly secondary to allergies but can also be caused by certain infections, medication reactions, autoimmune diseases, or other conditions. However, hypereosinophilia is rarely, if ever, explained by allergy alone and should always prompt a further workup. A meticulous approach to exploring key aspects of the medical history is recommended for assessing increased AECs because it helps to narrow the list of possible etiologies, and treatment varies, depending on the underlying diagnosis. Special attention should be paid to the onset of eosinophilia and any coincident events, such as travel or the start of new medications. Another critical part of the history is a thorough attempt to identify any possible eosinophil-associated end-organ damage, although a biopsy of suspected involved areas is often necessary for confirmation. Because the causes of an elevated AEC are broad, determining the trigger or underlying disorder becomes an important intellectual riddle that can usually be solved with careful attention to history, physical examination, and appropriate laboratory work.