|Year : 2015 | Volume
| Issue : 2 | Page : 60-62
Peripheral eosinophilia in a case of adenocarcinoma lung: A rare association
Bunkar Motilal1, Arya Savita2, Rajendra Takhar1
1 Department of Respiratory Medicine, Government Medical College, Kota, Rajasthan, India
2 Department of Dermatology, Government Medical College, Kota, Rajasthan, India
|Date of Web Publication||16-Jun-2015|
Assistant Professor (Respiratory Medicine), Qtr No 1/4, Medical College Campus, Kota - 324 010, Rajasthan
Source of Support: None, Conflict of Interest: None
Hypereosinophilia is a condition which coexists with a wide variety of allergic, infectious, paraneoplastic, and various systemic illnesses. These disorders may differ in severity varying from self-limiting to life-threatening on the basis of etiology. It is well-known fact that hypereosinophilia can occur in relation with a solid tumor; however, exact numbers of incidence are unknown. We present a case report of peripheral eosinophilia in a case of adenocarcinoma of the lung; a relation which is not frequently described in known literature.
Keywords: Adenocarcinoma, hypereosinophilia, lung, tumor
|How to cite this article:|
Motilal B, Savita A, Takhar R. Peripheral eosinophilia in a case of adenocarcinoma lung: A rare association. J Assoc Chest Physicians 2015;3:60-2
| Introduction|| |
Primarily eosinophilia usually associated with hematological malignancies, while secondary eosinophilia occurs in a variety of diseases, including all types of allergic diseases; parasitic infestations; skin diseases such as dermatitis herpetiformis, pemphigus, and mycosis fungoides, Loeffler's syndrome, pulmonary infiltration with eosinophilia (PIE syndrome), topical eosinophilia, and although unusual, any type of malignant disease especially with the dissemination or tumor necrosis. Nevertheless, the mechanism for eosinophilia in these diseases has not been elucidated.
Although hematological manifestation as a paraneoplastic syndrome is well-known entity with large cell carcinoma, which sometimes presents with eosinophilia. A rare case of adenocarcinoma of the lung with excessive eosinophilia in a young male is reported here.
| Case Report|| |
A 35-year-old nonsmoker, occasional alcoholic, and manual laborer male patient presented with complaints of bilateral diffuse chest pain, cough with minimal mucoid expectoration, low grade fever, and breathlessness for 3 months. There was no history of hemoptysis, hoarseness of voice, or constitutional symptoms like anorexia and weight loss. There was no past history of any medical illness like asthma/obstructive airway disease, diabetes mellitus, history of trauma or drug intake, etc.
On physical examination, respiratory rate was 20/min, pulse rate 112/min, and blood pressure was 126/76 mm Hg. There were no clubbing, cyanosis, dilated veins, pedal edema, and organomegaly. Respiratory system examination revealed bilateral inspiratory wheeze in both interscapular and infrascapular regions. Examination of other systems revealed nothing abnormal.
Basic lab findings revealed hemoglobin 8.4g/dl, white blood cell (WBC) count of 45,100/μL with 25% eosinophils, and absolute (total) eosinophils count of 11,300. Fasting blood sugar, renal function tests, and liver function tests were within normal limits. Human immunodeficiency virus (HIV) serology was negative. Sputum smear examination for acid fast bacilli was negative. Pulmonary function tests revealed mild obstructive pattern without reversibility and electrocardiographic findings were within normal limits. Ultrasonography of the abdomen revealed nothing abnormal. The stool was negative for ova and parasites, while level of immunoglobulin E was not abnormal in the blood.
Peripheral blood smear showed microcytic hypochromic anemia with mild anisocytosis, leukocytosis with marked eosinophilia, and adequate platelets [Figure 1]. Chest skiagram posteroanterior (PA) view showed bilateral conglomerating nodules and patchy pneumonitic lesion with airbronchogram in both lung fields, mainly in mid and lower zones, more predominantly in central area [Figure 2]a. Fiberoptic bronchoscopy showed no endobronchial growth and bronchoalveolar lavage (BAL) was negative for malignant cell cytology, cell count in BAL showed predominant lymphocyte and macrophages with eosinophil count ≈ 1%.
|Figure 2: (a) Chest X-ray posteroanterior (PA) view showing conglomerating nodules and patchy pneumonitic lesion on both lung fields predominantly in central area, (b) Chest X-ray showing bilateral multiple nodular opacity of varying sizes, some of them coalescing to each other|
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Initially, the patient was treated with oral steroid along with intravenous antibiotic, analgesics, bronchodilator, and symptomatic therapy. But the patient's general condition did not improve and repeat laboratory investigation revealed hemoglobin 7.5 g/dl, blood cell counts even worsened with aWBC count of 60,000/μL, 29% eosinophils, and absolute (total) eosinophils count reaching up to 17,400. Repeat chest X-ray showed progression of lesion and more dense opacity which were merging with one-together and appeared like solid mass lesion [Figure 2]b. Contrast-enhanced computed tomography (CECT) chest with high resolution section showed multiple lobulated as well as spiculated intraparenchymal mass seen in bilateral lung, largest measuring 10.4 × 10.4 × 8.7 cm in right middle and lower lobes. Few tiny subpleural nodules also seen-possibly of primary lung mass with bilateral lung metastasis [Figure 3].
|Figure 3: Contrast-enhanced computed tomography (CECT) thorax shows heterogeneously enhancing bilateral lobulated mass lesion|
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A trucut biopsy of the lung mass was performed without any complications. The pathologic examination showed clusters of pleomorphic neoplastic cells consistent with malignant epithelial lesion, suggestive of adenocarcinoma, a sub-type of non-small cell carcinoma. The tumor markers CK-7, TTF-1, and P-63 were strongly positive for neoplasm; however, it was negative for S100 protein, synaptophysin, and Melan A. A bone marrow biopsy was performed to find out leukemic process, which was negative for any existence of leukemia, confirming the reactive eosinophilia.
The patient was put on anticancer chemotherapy, but took only one cycle and discharged on request with advice to attend our institute for periodic follow-up assessment and treatment.
| Discussion|| |
Peripheral blood eosinophilia can be caused by numerous allergic, infectious, and neoplastic disorders; which require a variety of treatments. A major goal of the initial evaluation is to identify disorders that require specific treatments, for example, parasitic infection, drug hypersensitivity, connective tissue disorder, vasculitis, some drug ingestion, leukemia, and nonhematologic cancer. ,, Common target organs of eosinophils in disease include the skin, lung, and gastrointestinal tract. However, cardiac and nervous system damage can also occur, and can be more concerning and potentially life-threatening. Eosinophilia in solid malignancies is very rarely encountered;  however, these solid tumors may include thyroid, genitourinary, gastrointestinal, hepatocellular, and breast carcinoma. ,, In case of lung tumors, it has association in various types of cancer including oatcell carcinoma,  non-small cell carcinoma of lung, particularly with squamous cell and large cell carcinoma; but rarely reported in adenocarcinoma.  However, its pathogenesis is controversial. The existence of hypereosinophilia with no strong proof of an allergic reaction, any leukemic process on the bone marrow examination or parasitic infection favors paraneoplastic condition, as in our patient.
Mechanism of peripheral eosinophilia in bronchogenic carcinoma is poorly understood and is likely to be multifactorial with increased marrow production, prolonged peripheral survival, and in a minority the production of an eosinophilochemotactic factor. There are various theories which explain this phenomena. The best acknowledged and accepted theory which explained this phenomenon is stimulation of the bone marrow by circulatory factors secreted through tumor itself.  Other involved factors are interleukin-5 (IL-5), granulocyte-macrophage colony-stimulating factor (GM-CSF), and G-CSF. Balian et al.,  and Fridlender et al.,  described a patient with hepatocellular carcinoma and peripheral eosinophilia in whom the presence of intratumoral IL-5 was demonstrated by reverse transcription polymerase chain reaction (RT-PCR) analysis. The hypereosinophilia associated with the highly aggressive nature of the disease in our patient may be due to the high level of particular form of immunomodulator and growth factor, although these had never been analyzed. Other studies also found that aggressiveness of the tumor along with very poor prognosis is reflected by presence of eosinophilia in coexisting with malignancy. , The clinical course was marked by rapid progression and fatal outcome, despite adequate chemotherapy. Merely any study in literature which support that eosinophilia is associated with good prognosis or not associated with fetal outcome were reported. Wimazal et al., showed that eosinophils >350/μ Lpredicted a significantly reduced survival without having a significant impact on leukemia-free survival. 
In conclusion, the presence of peripheral eosinophilia should also evoke a suspicion of malignancy even in adults and should be considered in differentials/underlying etiology for this eosinophilia apart from other common causes.
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[Figure 1], [Figure 2], [Figure 3]