From the Guidelines
Eosinophilia and transaminitis should be managed by discontinuing any potentially offending medications, investigating for underlying causes, and considering corticosteroids for autoimmune conditions, as these conditions often occur together in drug reactions, parasitic infections, and autoimmune conditions. When these findings are present, common culprits include antibiotics, antiepileptics, NSAIDs, and antipsychotics. Diagnostic workup should include:
- Complete blood count with differential
- Comprehensive metabolic panel
- Hepatitis serologies
- Autoimmune markers (ANA, ANCA)
- Parasite screening (stool studies, Strongyloides serology) 1 For drug-induced cases, symptoms typically resolve within 2-4 weeks after discontinuing the offending agent. For parasitic infections, treatment depends on the specific organism identified; for example, albendazole 400mg twice daily for 3-7 days for many helminth infections. For autoimmune conditions like eosinophilic gastroenteritis or EGPA (formerly Churg-Strauss), corticosteroids may be necessary, starting with prednisone 0.5-1mg/kg/day 1. The connection between eosinophilia and liver injury stems from eosinophils releasing cytotoxic proteins and inflammatory mediators that damage hepatocytes, leading to elevated transaminases. Persistent unexplained eosinophilia with transaminitis warrants referral to gastroenterology or hepatology for possible liver biopsy to rule out eosinophilic hepatitis or other serious conditions. Recent studies have also highlighted the importance of monitoring and managing transaminitis in the context of gene therapy, with recommendations for strict laboratory monitoring and prompt administration of immunosuppression, typically corticosteroids, to resolve the transaminitis and attempt to retain transgene expression 1.
From the Research
Eosinophilia and Transaminitis
- Eosinophilia is defined as an elevation of eosinophils in the bloodstream, with a count of 450-550 cells/μL 2.
- The causes of eosinophilia are various and can be summarized by the acronym "APLV", which refers to Allergic disorders, Parasitic infections, Leukemia/Lymphomas, and Vasculitis-Immunodeficiency diseases 3.
- Eosinophilia can be associated with organ damage, mainly at the cardiac, pulmonary, and cutaneous levels, due to the release of granule products, lipidic mediators, and cytokines 3.
- Drug-induced eosinophilia is a diagnosis of exclusion, and most cases are asymptomatic, but can be associated with an increased rate of hypersensitivity reactions 4.
- The World Health Organization-defined eosinophilic disorders include a broad range of nonhematologic and hematologic disorders with potential for end-organ damage, and diagnosis relies on morphologic review, cytogenetics, and molecular assays 5.
- Eosinophils play a role in autoimmune diseases, including inflammatory bowel diseases, neuromyelitis optica, and bullous pemphigoid, and their function in these diseases includes degranulation, immune modulation, and antigen presentation 6.
- Transaminitis, or elevated liver enzymes, can be associated with eosinophilia in certain conditions, such as hypereosinophilic syndrome or eosinophilic granulomatosis with polyangiitis, but the exact relationship between eosinophilia and transaminitis is not well established 3, 5, 6.