Immunology Review Corner

Immunology Review Corner: Chapter 63 of the 6th edition of Middleton’s Allergy Principles and Practice, edited by N. Franklin Adkinson, et al.

Prepared by Drs. Eric Chenworth, Mayo Clinic; Karla R. Davis, Walter Reed Medical Center; Anne K. Ellis, McMaster University; and Soo Kim-Delio, Walter Reed Army Medical Center.

Chapter 63: Eosinophilia and Eosinophil-Related Disorders

1. A 47-year-old man receiving IV cefazolin for a susceptible infection is noted to have deteriorating renal function. Which of the following statements regarding drug-induced acute interstitial nephritis (AIN) is most accurate?

A. All renal biopsies of AIN patients demonstrate tissue eosinophilia.
B. The sensitivity of eosinophiluria for AIN approaches 100 percent.
C. The presence of eosinophiluria is neither sensitive nor specific for drug-induced AIN.
D. An eosinophilic renal infiltrate indicates a drug-induced etiology for AIN.

2. A 50-year-old woman with gastroesophageal reflux disease (GERD) on chronic therapy with ranitidine is diagnosed with eosinophilic myocarditis, and referred for evaluation of a possible contributing hypersensitivity. Which of the following is most correct?

A. Eosinophilic myocarditis is never due to a hypersensitivity.
B. Eosinophilic myocarditis is a common, self-limited condition, often resulting from aeroallergen exposure.
C. Eosinophilic myocarditis is a rare disorder that may, in some cases, be due to a reaction to ranitidine.
D. Eosinophilic myocarditis is exclusively due to drug-eluting stents placed for therapy of coronary artery disease.

3. Which of the following cytokines is principally responsible for increases in eosinophilopoiesis?

A. GM-CSF
B. IL-3
C. IL-4
D. IL-5

4. A 34-year-old woman with a history of childhood asthma has been taking a non-steroidal anti-inflammatory drug (NSAID) for a period of 3 months. She denies the use of any other medications or dietary supplements. Over the past month, she has been developing increasing cough, dyspnea, and wheezing, as well as an urticarial skin rash. She is sent to you for evaluation of possible asthma. Relevant labs include a CBC demonstrating a hemoglobin of 11.8 g/dL, WBC count of 10.4 x 109/L [normal range 3.5-10.5 x 109/L] with 1.5 x 109/L eosinophils [normal range 0.05 - 0.5 x 109/L]. Pulmonary function testing demonstrates an obstructive pattern with some bronchodilator response. Chest x-ray demonstrates peripheral subpleural and bibasilar infiltrates. A BAL demonstrated numerous eosinophils. After the appropriate diagnosis was made, the NSAID medication was discontinued and she was treated with a short course of oral corticosteroids with resolution of symptoms within a few days. Which of the following is the most accurate statement regarding the patient’s illness?

A. The pulmonary symptoms would promptly recur after re-challenge with the NSAID medication.
B. The patient’s pulmonary symptoms would resolve after further administration of the NSAID.
C. NSAIDs are not a known cause of the patient’s illness.
D. Primary management centers on inhaled corticosteroid therapy.

5. A previously healthy 54-year-old male presents with a 4- by 5-centimeter erythematous swelling on his lateral calf. The lesion is minimally tender, not warm to palpation, and has failed to respond to antibiotics. Eosinophilia is noted on his CBC. A biopsy report mentions “flame figures.” Which of the following is the most likely diagnosis?

A. Wells’ Syndrome
B. Cellulitis
C. Erythema Nodosum
D. Granuloma Annulare

6. Which of the following diseases must be excluded before instituting empiric corticosteroid therapy for hypereosinophilia?

A. Strongyloidiasis
B. Schistosomiasis
C. Clonorchiasis
D. Onchocerciasis

7. Findings of cysts and nodules on high-resolution chest CT is nearly pathognomonic for which of the following conditions?

A. Acute Eosinophilic Pneumonia
B. Eosinophilic Granuloma
C. Allergic Bronchopulmonary Aspergillosis
D. Churg-Strauss Syndrome

8. Which of the following organs or systems is most frequently involved in patients with the Idiopathic Hypereosinophilic Syndrome?

A. Neurologic
B. Splenic
C. Ocular
D. Cutaneous

9. Episodic Angioedema with Eosinophilia is associated with elevations in which serum immunoglobulin?

A. IgG
B. IgA
C. IgM
D. IgE

10. Which of the following parasites characteristically localizes within the pulmonary parenchyma and elicits eosinophil-enriched inflammatory reactions?

A. Toxocara canis
B. Ascaris
C. Strongyloides
D. Paragonimus

11. Which of the following laboratory findings in patients with the Idiopathic Hypereosinophilic Syndrome is associated with a better prognosis?

A. Elevated IgE levels
B. Elevated vitamin B12 levels
C. Basophilia
D. Cytogenetic abnormalities

12. Which of the following eosinophilic diseases has a 2:1 female predominance?

A. Chronic Eosinophilic Pneumonia
B. Idiopathic Hypereosinophilc Syndrome
C. Kimura’s Disease
D. Acute Eosinophilic Pneumonia


Answers:
1. C, pages 1107,1109
2. C, page 1109
3. D, page 1105
4. A, page 1107
5. A, page 1113
6. A, page 1106
7. B, page 1117
8. D, page 1110
9. C, page 1113
10. D, page 1115
11. A, page 1111
12. A, page 1115