Tropical Pulmonary Eosinophilia

Tropical Pulmonary
Eosinophilia
DR. MD. SHAFIQUL ISLAM DEWAN
RESIDENT (PULMONOLOGY)
DHAKA MEDICAL COLLEGE HOSPITAL
05/11/2023 1
Tropical pulmonary eosinophilia
(TPE)
Tropical pulmonary eosinophilia (TPE) is a clinical manifestation of lymphatic filariasis, a parasitic
infection caused by filarial nematodes (roundworms) that inhabit the lymphatics and bloodstream.
Three species cause human lymphatic filariasis: Wuchereria bancrofti, Brugia malayi, and Brugia
timori.
Infection is transmitted by mosquito vectors; humans are definitive hosts.
TPE is caused by an immune hyper-responsiveness to microfilariae that become trapped in the

lungs
05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 2

Filariae
Filariae have five morphologic stages.
Humans are infected with third-stage larvae transmitted by mosquitoes.
Infective larvae molt twice and develop into adults that survive in a human
host for up to 20 years.
The first-stage larvae, or microfilariae, are released into the circulation by

female adult worms.

Epidemiology
TPE can occur in any tropical area where filariasis occurs and is most common among
young adults.
It is more common in individuals from the indian subcontinent and occurs four to seven
times more frequently in males than in females.
Rare cases have been described in children.
The majority of cases of TPE occur in endemic areas; cases in nonendemic settings have
also been described.

Pathogenesis
Pulmonary disease reflects a robust immunologic response against blood borne microfilariae
that become trapped within the lung and reticuloendothelial organs.
TPE develops in less than 0.5 percent of patients with lymphatic filariasis;
The earliest histopathologic finding is histiocytic infiltration.
Approximately one month following infection, an eosinophilic interstitial infiltrate develops.
In more severe cases, eosinophilic abscesses, eosinophilic bronchopneumonia, or eosinophilic
granulomas may be observed.
With chronic disease, there is an ongoing eosinophil interstitial infiltration and increasing
pulmonary fibrosis.
Occasionally, microfilarial fragments may be identifiable in biopsied lung or reticuloendothelial
tissues.

Clinical Features
Clinical manifestations is usually gradual.
TPE is seen predominantly (80%) in men, usually in middle age.
Nocturnal paroxysmal cough and bronchospasm
Low-grade fever
Weight loss
Lymphadenopathy
Some patients also have hepatosplenomegaly.

Physical Examination
Chest findings are minimal or absent in most patients.
In some cases, rhonchi, crepitations(especially over the midzones and

bases).
Lymphadenopathy, hepatomegaly, and/or splenomegaly are observed in

approximately 15percent of patients.
Cor pulmonale is a rare complication.

Investigation
Complete blood count (Leukocytosis, marked eosinophilia,usually above 3000/microL)
Serum igE level (marked increased, often above 1000units/mL)
Antibodies to filarial antigens (Diagnostic)
CXR, CT scan
Spirometry (Restrictive & Obstructive)
Sputum examination (Eosinophil)
BAL (Increased eosinophil)
**Although TPE is caused by filaria, patients with TPE do not have detectable
microfilaremia.

Chest Radiographs
Usually increased bilateral bronchovascular markings and
reticulonodular opacities or diffuse miliary lesions, or opacities in the
middle and lower lung fields.
Cavitation, bronchiectasis, and pleural effusion have been reported but

are uncommon;
Chest radiographs may also be normal.

Treatment of TPE
Specific treatment: Diethylcarbamazine (6 mg/kg/day in three doses for12 to 21
days) (Grade 1B).
Bronchospasm: Managed with bronchodilators and in severe cases, short-term

corticosteroids.
Relapses: Treated with a repeat course of the same treatment regimen.

**Corticosteroid therapy has been used as adjunctive therapy to reduce
inflammation in the acute setting but is not definitive therapy for TPE.

Differential Diagnosis
Chronic eosinophilic pneumonia,
Drug hypersensitivity reactions,
Fungal pneumonia,
Pulmonary syndromes associated with other helminths (most commonly
toxocara hookworm, ascaris, and strongyloides).
**Among these, strongyloidiasis is most important to exclude since
corticosteroid administration can lead to fatal dissemination o finfection.
**Although the imaging studies in TPE can mimic miliary tuberculosis the
presence of marked eosinophilia in TPE is an important distinguishing feature.

(A) Chest radiograph of a patient with confirmed tropical pulmonary eosinophilia
shows subpleural right lung consolidation, subpleural left midlung opacity, and
bilateral perihilar interstitial thickening.
(B) Chest radiograph of the same patient after treatment with diethylcarbamazine.
Note the improved opacities.

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Tropical Pulmonary

Infection is transmitted by mosquito vectors; humans are definitive hosts.

TPE is caused by an immune hyper-responsiveness to microfilariae that become trapped in the

05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 2

Humans are infected with third-stage larvae transmitted by mosquitoes.

The first-stage larvae, or microfilariae, are released into the circulation by

05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 3

Rare cases have been described in children.

05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 4

05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 5

05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 6

In some cases, rhonchi, crepitations(especially over the midzones and

Lymphadenopathy, hepatomegaly, and/or splenomegaly are observed in

Cor pulmonale is a rare complication.

05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 7

05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 8

Cavitation, bronchiectasis, and pleural effusion have been reported but

Chest radiographs may also be normal.

05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 9

Bronchospasm: Managed with bronchodilators and in severe cases, short-term

Relapses: Treated with a repeat course of the same treatment regimen.

05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 10

05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 11

05/11/2023 DR. MD. SHAFIQUL ISLAM DEWAN, RESIDENT (PULMONOLOGY), DMCH 12

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