Case History
A 38-year-old male, migrant worker, a returnee from Malaysia presented to the outpatient Department of Internal Medicine at Dhulikhel Hospital, Nepal with a history of dry cough and exertional shortness of breath for two weeks. In investigations, the laboratory findings suggested peripheral eosinophilia (AEC: 8000/µL) and his chest x-ray showed left-sided pleural effusion (Figure 1).
Suspecting a potential parasitic infestation, he was initially managed with oral antiparasitic medications that included tablet praziquantel 75mg/kg/day in three divided doses for 3 days and tablet Ivermectin 12 mg once daily for 3 days. As he was progressing gradually during hospital admission, he got discharged after three days of admission with the prescription of oral steroids (prednisolone 1mg/kg/day) for 14 days.
A week after, the patient revisited the emergency department with complaints of sudden onset shortness of breath for a few hours. A Chest X-ray was repeated, which revealed bilateral hydro-pneumothorax with collapsed lungs (Figure 2). A diagnostic and therapeutic tube thoracotomy was performed by inserting chest tubes on both sides. Purulent pleural fluid was present, whose analysis showed increased eosinophil and lymphocyte with adenosine deaminase (ADA) value of >100IU/L. (Table 2). Then, the case started receiving anti-tubercular therapy (ATT) and continued the prednisolone. This was based on the pleural fluid analysis reports keeping pleural tuberculosis as the differential diagnosis through his sputum gene xpert was negative for Mycobacterium tuberculosis . After this medication, his shortness of breath and other clinical status were improving. Despite the completion of the initiation phase of the ATT, his cough could not subside, and his AEC remained more than 25000/µL. These findings raised the suspicion of eosinophilic leukemia prompting a bone marrow aspiration and biopsy along with Fluorescent In-situ Hybridization (FISH) analysis–the results of which have been mentioned below in table 1.