Q:

6/11/2014
I would like to ask for a suggestion for a patient with eosinophilia and high IgE. He is a 34 year-old man with long standing history of eczema. His eczema's become difficult to treat in the past few years as he required frequent oral steroid bursts for eczema exacerbation. Topical steroids, TCIs, antihistamine, low dose cyclosporin, phototherapy failed to improve his eczema. He was seen by a dermatologist in Taiwan and was treated with Xolair with some improvement. On evaluation, eosinophil of 1600 and IgE of 18500 were found. Other routine labs were normal. Stool exam for parasites was negative. Skin biopsy was not done as the derm thought it was consistent with eczema. He has recently relocated to Thailand. Xolair was discontinued due to financial issue. His eczema now is stable but he still has widespread xerosis. He has a history of atopy, allergic rhinoconjuncitivits with positive skin tests to many aeroallergens, mainly HDM. He has no asthma, no sinusitis, no recurrent infections. He is not taking regular meds.

I wonder that his eosinophilia and high IgE could be the result of his severe eczema or vice versa. I realize that diffdx for eosinophilia is broad and work up could be limitless. He was reluctant to have extensive investigation because of financial constraints, the long standing disease and he felt that he was doing well otherwise. However, given the severity of his eczema and very high Eo and IgE, I think it's worth to have some tests. In your opinion, what mandatory tests do you think he should undergo? In terms of his difficult to treat eczema, do you think allergen immunotherapy could be helpful?

A:

Thank you for your inquiry.

Your patient, with a marked elevation of IgE, severe atopic dermatitis, and eosinophilia is not an uncommon presentation. However, in most patients, one finds no specific cause for this symptom complex, and treatment remains symptomatic. There is no specific mandated test that I would suggest for further workup. And, unfortunately, it is doubtful that allergen immunotherapy would be of much help in your patient. Your statement regarding the difficulty in establishing a cause for eosinophilia is well taken, and it is doubtful, as mentioned above, that you will find such a cause. I am afraid the treatment would be purely symptomatic for his eczema and atopic manifestations. Hopefully anti-IL5 will become available soon, and you might consider the use of this biologic agent.

In summary, I think you have done due diligence in your evaluation, and considering his economic circumstance, I would be prudent with further testing. I cannot think of any specific test that I would consider mandated at this point. I believe treatment should be the traditional therapy for his symptoms and if anti-IL5 becomes available, I would strongly consider, if financial circumstances allowed, the use of this agent.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology