What is the appropriate management for a patient with generalized body ache, elevated C-Reactive Protein (CRP), and eosinophilia?

Management of Generalized Body Ache with Elevated CRP and Eosinophilia

This patient requires immediate evaluation for parasitic infection with empirical treatment of albendazole 400 mg plus ivermectin 200 μg/kg if travel history to endemic regions exists, while simultaneously ruling out serious systemic conditions including eosinophilic granulomatosis with polyangiitis (EGPA) and hypereosinophilic syndrome (HES). 1

Initial Diagnostic Approach

Essential Travel and Exposure History

• Document detailed travel history to tropical/subtropical regions, particularly Southeast Asia, Africa, Central/South America, or Eastern Europe, as parasitic infections are the most common cause of eosinophilia in returning travelers 2
• Inquire about consumption of raw or undercooked meat (particularly pork), fish, snails, prawns, crabs, or frogs 2
• Ask about freshwater exposure (swimming, wading) for schistosomiasis risk 2

Critical Laboratory Investigations

• Complete blood count with differential to quantify absolute eosinophil count (this patient has 1.0 × 10⁹/L, which meets the threshold for hypereosinophilia) 2, 1
• Stool studies: concentrated stool microscopy (minimum 3 samples) and PCR for parasites 2, 1
• Serology for parasites: Strongyloides, Schistosoma, Toxocara, Trichinella (available through specialized tropical disease centers) 2
• ANCA testing (both MPO-ANCA and PR3-ANCA) to evaluate for EGPA, as 30-40% of EGPA patients are ANCA-positive 2
• Urinalysis for hematuria and proteinuria to assess for glomerulonephritis 2, 3
• Creatine kinase level (elevated in trichinellosis and some vasculitides) 2

Assess for End-Organ Involvement

The presence of eosinophilia with systemic symptoms mandates evaluation for organ damage:

Cardiac assessment (highest priority for morbidity/mortality):

• ECG and echocardiogram to evaluate for eosinophilic cardiomyopathy, which can occur in HES, EGPA, and trichinellosis 2

Pulmonary evaluation:

• Chest imaging (CT preferred) for infiltrates, nodules, or pleural effusion 2, 3
• Consider pulmonary function tests if respiratory symptoms present 3

Neurological examination:

• Assess for peripheral neuropathy (mononeuritis multiplex is characteristic of EGPA) 2
• If CNS symptoms present, obtain MRI brain/spine and consider lumbar puncture with specific request for eosinophil count in CSF 2

Other systems:

• Skin examination for purpura, nodules, or urticarial rash 2
• Assess for rhinosinusitis symptoms or nasal polyps (suggestive of EGPA) 2

Treatment Algorithm

If Travel History to Endemic Regions Present:

Empirical antiparasitic therapy is recommended as first-line treatment while awaiting diagnostic results, as parasitic infections are the most common reversible cause and delayed treatment can lead to complications 1:

• Albendazole 400 mg single dose PLUS ivermectin 200 μg/kg single dose 1
• This combination covers the most common helminthic infections including strongyloidiasis, hookworm, and other soil-transmitted helminths 2, 1

Important caveat: If strongyloidiasis is suspected or confirmed, do NOT initiate corticosteroids before treating with ivermectin, as steroids can cause fatal hyperinfection syndrome 2

If Specific Parasites Identified:

• Schistosomiasis: Praziquantel 40 mg/kg in divided doses for 1-3 days 2, 1
• Trichinellosis (if severe myalgia, periorbital edema, very high eosinophils >3 × 10⁹/L): Albendazole 400 mg daily for extended course 2
• Liver flukes: Praziquantel 25 mg/kg three times daily for 2-3 days 2

If No Travel History or Parasitic Workup Negative:

Evaluate for EGPA if the following features are present:

• Asthma or chronic rhinosinusitis 2
• Peripheral neuropathy 2
• Lung infiltrates 2
• Palpable purpura or other skin lesions 2

ACR-EULAR 2022 criteria (score ≥6 suggests EGPA in context of small/medium vessel vasculitis):

• Eosinophil count ≥1 × 10⁹/L: +5 points 2
• Obstructive airway disease: +3 points 2
• Nasal polyps: +3 points 2
• Mononeuritis multiplex/motor neuropathy: +1 point 2

Treatment for EGPA with organ-threatening manifestations:

• Glucocorticoids (prednisone 1 mg/kg/day, typically 40-60 mg daily) as initial therapy 2, 4
• Add cyclophosphamide or rituximab for severe disease with renal insufficiency, cardiomyopathy, GI involvement, or CNS involvement 2

If Idiopathic Hypereosinophilic Syndrome (HES) Suspected:

HES is a diagnosis of exclusion requiring:

• Sustained eosinophilia ≥1.5 × 10⁹/L for at least 6 months 5, 6
• Evidence of end-organ damage 5, 6, 7
• Exclusion of secondary causes and clonal eosinophilia 5, 6, 7

Molecular testing is critical:

• Test for PDGFRA, PDGFRB, or FGFR1 rearrangements, as these predict response to imatinib 5, 6, 7
• If fusion-positive: Imatinib is the treatment of choice with dramatic responses 6, 7
• If fusion-negative: Prednisone 1 mg/kg/day is first-line therapy 5, 6, 7

Symptomatic Management:

While awaiting definitive diagnosis:

• Topical emollients and antihistamines for pruritus 1
• Avoid corticosteroids until strongyloidiasis is definitively excluded 2
• Monitor closely for development of organ involvement, particularly cardiac complications 2, 6

Critical Pitfalls to Avoid

• Never start corticosteroids before excluding or treating strongyloidiasis in anyone with potential exposure, as this can cause fatal disseminated infection 2
• Do not rely on single stool sample - sensitivity is poor; obtain at least 3 concentrated specimens 2
• Do not dismiss normal ANCA - 60-70% of EGPA patients are ANCA-negative, particularly those with cardiac involvement 2
• Do not delay cardiac evaluation - eosinophilic cardiomyopathy can be rapidly progressive and life-threatening 2, 6
• Do not assume symptoms correlate with disease activity - significant organ damage can occur with minimal symptoms 8, 6

Follow-Up Strategy

• Repeat eosinophil count in 2-4 weeks after empirical antiparasitic therapy 1
• If eosinophilia persists despite treatment, proceed with comprehensive evaluation for primary eosinophilic disorders 5, 6, 7
• Serial cardiac monitoring if eosinophilia remains elevated, as cardiac involvement can develop insidiously 6, 7