Case History
A 38-year-old male, migrant worker, a returnee from Malaysia presented
to the outpatient Department of Internal Medicine at Dhulikhel Hospital,
Nepal with a history of dry cough and exertional shortness of breath for
two weeks. In investigations, the laboratory findings suggested
peripheral eosinophilia (AEC: 8000/µL) and his chest x-ray showed
left-sided pleural effusion (Figure 1).
Suspecting a potential parasitic infestation, he was initially managed
with oral antiparasitic medications that included tablet praziquantel
75mg/kg/day in three divided doses for 3 days and tablet Ivermectin 12
mg once daily for 3 days. As he was progressing gradually during
hospital admission, he got discharged after three days of admission with
the prescription of oral steroids (prednisolone 1mg/kg/day) for 14 days.
A week after, the patient revisited the emergency department with
complaints of sudden onset shortness of breath for a few hours. A Chest
X-ray was repeated, which revealed bilateral hydro-pneumothorax with
collapsed lungs (Figure 2). A diagnostic and therapeutic tube
thoracotomy was performed by inserting chest tubes on both sides.
Purulent pleural fluid was present, whose analysis showed increased
eosinophil and lymphocyte with adenosine deaminase (ADA) value of
>100IU/L. (Table 2). Then, the case started receiving
anti-tubercular therapy (ATT) and continued the prednisolone. This was
based on the pleural fluid analysis reports keeping pleural tuberculosis
as the differential diagnosis through his sputum gene xpert was negative
for Mycobacterium tuberculosis . After this medication, his
shortness of breath and other clinical status were improving. Despite
the completion of the initiation phase of the ATT, his cough could not
subside, and his AEC remained more than 25000/µL. These findings raised
the suspicion of eosinophilic leukemia prompting a bone marrow
aspiration and biopsy along with Fluorescent In-situ Hybridization
(FISH) analysis–the results of which have been mentioned below in table
1.