A 16-year-old boy exhibited pruritic indurated plaques and papules on the lower extremities (Fig. 1A) for 15 days; He complained of tingling sensation and a mild weakness in his left leg and right arm. A skin biopsy from the individual leg revealed numerous eosinophils in the perivascular and periadnexal inflammatory infiltrate, and sub- cutis (Fig. 1B). Laboratory data revealed that the white blood cell count was 14,200 per mm3 with 31% eosinophils. A peripheral blood smear showed a marked eosinophilia. On the other hand, normal results were found from the liver and renal function test. The creatine phosphokinase isoenzyme level was within normal range. The total IgE level was greater than 2,500 IU/mL. The electrocardiogram, echocardiogram, chest X-ray, pulmonary function test, abdominal ultrasonography, and ophthalmolo- gical examination were normal. There was no evidence of a parasitic infestation from the stool examination and serologic tests. We suspected eosinophilic cellulites and started the treatment with 60 mg prednisolone daily. Within 5 days, his eosinophil count returned to 3% and the itching sensation subsided. However, the sensory and motor disturbances still remained. The neuropathy was documented by nerve conduction studies and electromyography (EMG), which revealed reduced amplitude of the sensory and motor evoked responses and slowed conduction velocities that were consistent with mononeuritis multiplex.
After 5 months abdominal pain developed and the white blood cell count was 24,800 per mm3 with 60% eosinophils; the patient was admitted to the department of pediatrics. Abdominal pain subsided with only conservative treatment in two days and abdominal ultrasonography was normal. From June 2005 to April 2006, his eosinophil count remained at more than 40%. The patient demonstrated a prolonged period (> 6 months) of hypereosinophilia but lacked evidence of parasitic, allergic, or any other recognized cause of eosinophilia, or symptoms and signs of the skin and peripheral nervous system involvement. This fulfilled the criteria for HES. canadian antibiotics
Fig. 1. (A) Multiple, indurated plaques and crusted papules on both edematous legs. (B) Extensive eosinophil infiltration in the dermis (H&E, original magnification, x200).
During the follow-up periods, the skin lesion had waxed and waned regardless of the low dose maintenance steroid therapy. Six months later, the results of his neurologic examination were much improved, with manual muscle testing after rehabilitation and physical therapy. In addition, his eo- sinophil count level had somewhat decreased, though still elevated.