Journal of Infection (2010) 60,1e20 www.elsevierhealth.com/journals/jinf CLINICAL GUIDELINES OF THE BRITISH INFECTION SOCIETY Eosinophilia in returning travellers and migrants from the tropics: UK recommendations for investigation and initial management Anna M. Checkley a,*, Peter L. Chiodini a, David H. Dockrell b, Imelda Bates c, Guy E. Thwaites a, Helen L. Booth d, Michael Brown a, Stephen G. Wright a, Alison D. Grant a, David C. Mabey a, Christopher J.M. Whitty a, Frances Sanderson e, On behalf of the British Infection Society and The Hospital for Tropical Diseases a Hospital for Tropical Diseases, Capper Street, London WC1E 6JB, UK b Section of Infection, Inflammation and Immunity, University of Sheffield, School of Medicine and Biomedical Sciences, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK c Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK d University College London Hospitals NHS Trust, 235 Euston Road, London NW1 2BU, UK e Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK Accepted 13 November 2009 KEYWORDS Summary Eosinophilia is a common finding in returning travellers and migrants, and in this Eosinophilia; group it often indicates an underlying helminth infection. Infections are frequently either Helminth; asymptomatic or associated with non-specific symptoms, but some can cause severe disease. Traveller; Here the British Infection Society guidelines group reviews common and serious infectious Migrant; causes of eosinophilia, and outlines a scheme for investigating returning travellers and mi- Investigation; grants. All returning travellers and migrants with eosinophilia should be investigated with con- Management centrated stool microscopy and strongyloides serology, in addition to tests specific to the region they have visited. Terminal urine microscopy and serology for schistosomiasis should also be performed in those returning from Africa. Eosinophilia is also a feature of significant non-infective conditions, which should be considered. ª 2009 The British Infection Society. Published by Elsevier Ltd. All rights reserved. * Corresponding author at: Jenner Vaccine Institute, ORCRB, Roosevelt Drive, Oxford OX3 7DQ, UK. Tel.: þ44 1865 617636; fax: þ44 1865 617608. E-mail address: [email protected] (A.M. Checkley). 0163-4453/$36 ª 2009 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2009.11.003 2 A.M. Checkley et al. Contents 1. Introduction ...................................................................................... 3 2. General principles ................................................................................. 3 2.1 Patient group ............................................................................... 3 2.2 Geographical area ........................................................................... 3 2.3 Timing ..................................................................................... 3 2.4 Serology ................................................................................... 3 3. Investigating asymptomatic eosinophilia ............................................................... 3 4. Eosinophilia associated with specific symptoms ........................................................ 8 4.1 Eosinophilia with fever and/or respiratory symptoms .............................................. 8 4.1.1 Katayama syndrome - Schistosoma sp. ................................................... 8 4.1.2 Loeffler’s syndrome ................................................................... 8 4.1.3 Visceral larva migrans/acute toxocariasis - Toxocara canis and T. catis ........................ 9 4.1.4 Tropical pulmonary eosinophilia - Wuchereria bancrofti and Brugia malayi .................... 10 4.1.5 Pulmonary hydatid disease (Echinococcus granulosus and E. multilocularis) ................... 10 4.1.6 Paragonimiasis (Paragonimus sp.) ....................................................... 10 4.1.7 Coccidioidomycosis and paracoccidioidomycosis - Coccidioides immitis, Paracoccidioides braziliensis ......................................................................... 10 4.1.8 Other causes of peripheral eosinophilia and pulmonary infiltrates ........................... 11 4.2 Eosinophilia with gastrointestinal symptoms .................................................... 11 4.2.1 Strongyloidiasis - Strongyloides stercoralis ............................................... 11 4.2.2 Schistosomiasis/bilharzia with gastrointestinal symptoms - Schistosoma mansoni and S. japonicum 11 4.2.3 Ascariasis-Ascaris lumbricoides ......................................................... 11 4.2.4 Tapeworm - Taenia saginata/T. solium .................................................. 12 4.2.5 Dwarf tapeworm - Hymenolepis nana ................................................... 12 4.2.6 Hookworm - Ancylostoma duodenale/Necator americanus .................................. 12 4.2.7 Whipworm - Trichuris trichiura ......................................................... 12 4.2.8 Pin worm - Enterobius vermicularis ..................................................... 12 4.2.9 Trichinellosis - Trichinella sp. .......................................................... 12 4.2.10 Anisakiasis - Anisakis spp. and Pseudoterranova decipiens ................................. 12 4.2.11 Angiostrongylus costaricensis ......................................................... 13 4.2.12 Other causes of eosinophilia and GI symptoms ........................................... 13 4.3 Eosinophilia and right upper quadrant pain/jaundice ............................................. 13 4.3.1 Hydatid disease in the liver - Echinococcosis granulosus and E. multilocularis ................. 13 4.3.2 Fasciola hepatica/F. giganta ........................................................... 13 4.3.3 Liver flukes: Clonorchis sinensis and Opisthorchis sp. ...................................... 13 4.3.4 Schistosomiasis - S. mansoni and S. japonicum ........................................... 14 4.4 Eosinophilia with neurological symptoms ....................................................... 14 4.4.1 Angiostrongylus cantonensis - rat lung worm ............................................. 14 4.4.2 Gnathostomiasis - Gnathostoma spinigerum .............................................. 14 4.4.3 Neurocysticercosis causing meningitis - T. solium ......................................... 14 4.4.4 Schistosomiasis/bilharzia and CNS symptoms - Schistosoma haematobium, S. mansoni, S. japonicum (4.2.2) ............................................................................. 14 4.4.5 Toxocariasis - T. canis, T. catis (4.1.3) .................................................. 15 4.4.6 Coccidioidomycosis and paracoccidioidomycosis - C. immitis, P. braziliensis (4.1.7) ............ 15 4.4.7 Other causes ........................................................................ 15 4.5 Eosinophilia with skin/musculokeletal symptoms ................................................ 15 4.5.1 Onchocerciasis - Onchocerca volvulus ................................................... 15 4.5.2 Larva currens - S. stercoralis .......................................................... 15 4.5.3 Lymphatic filariasis - W. bancrofti, B. malayi ............................................. 15 4.5.4 Loiasis - Loa loa ..................................................................... 16 4.5.5 Gnathostomiasis - Gnathostoma spinigerum .............................................. 16 4.5.6 Trichinellosis - Trichinella spiralis ...................................................... 16 4.5.7 Swimmers’ itch/cercarial dermatitis - Schistosoma sp. ..................................... 16 4.6 Eosinophilia and urinary symptoms ............................................................ 16 4.6.1 Schistosomiasis/bilharzia - Schistosoma haematobium (4.2.2) ............................... 16 5. Conclusion ...................................................................................... 17 Investigation and initial management of eosinophilia in returning travellers and migrants 3 Acknowledgements ............................................................................... 17 References ...................................................................................... 17 1. Introduction infection1,2,16,17 while travellers are often newly infected and have a greater immune response with more pronounced eosinophilia.18 Infection with multiple helminth species may Eosinophilia occurs commonly in individuals returning from occur in migrants, however, which is also associated with the tropics. In a UK series of 852 asymptomatic returning more pronounced eosinophilia.2,3 Rare complications of travellers, 8% had eosinophilia,1 and in a Canadian series chronic schistosomiasis such as bladder carcinoma or portal of 1605 individuals returning from the tropics 10% of asymp- hypertension are more often seen in migrants, whereas tomatic individuals had eosinophilia.2 For the purpose of Katayama syndrome and Loeffler’s syndrome are more these recommendations, eosinophilia is defined as a periph- frequent in travellers. eral blood eosinophil count of >0.45 Â 109/L. Helminth infection is the commonest identifiable cause of eosinophilia in the returning traveller or migrant, rates 2.2. Geographical area varying from 14%2 to 64%.3 However there are multiple causes, both infectious and non-infectious, of a peripheral The incidence