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How would you treat a patient with erythroderma and progressive eosinophilia?

September 27, 2024

October 2024

We asked, and you answered! Here are the responses from this month’s “You Make the Call” question on treatment options for a patient with erythroderma and progressive eosinophilia. 


Disclaimer: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is solely at your own risk.


I would request a T-cell gene rearrangement study for this patient.

Hasan Al-Yaseen, MRCP, PhD
Dubai, United Arab Emirates

I would recommend mepolizumab.

Juan José Gil Fernández, MD, PhD
Madrid, Spain

After going through the case history and other investigative reports, this looks like a lymphocytic variant of hypereosinophilic syndrome (HES). Histopathology usually shows lichenoid dermatitis without epidermotropism. Inflammatory infiltrate in the dermis is principally composed of eosinophilic cells and lymphocytes. Serum immunoglobulin E could be high as it is TH2 phenotype, and peripheral blood immunophenotyping shows atypical T-cell lymphocyte proliferation in CD4(+) and CD3(-), and clonal TCR gene rearrangement favors lymphocytic HES.

I would treat this patient with prednisolone 1 mg/kg daily along with pegylated interferon alpha.

Abdulrahman Saifudeen, MBBS, MD, MRCP
Kerala, India

Though the patient is PDGFRA negative, I would suggest trying imatinib. We have reported on a similar case with a PDGFRA-negative lymphocytic variant of hypereosinophilic syndrome (L-HES) that went into a prolonged remission with imatinib (Am J Hematol, 2011).

Another option for this patient could be mepolizumab. In the randomized trial from 2008, mepolizumab showed considerable efficacy in patients with PDGFRA-negative L-HES, though the response was somewhat weaker than the one in patients without L-HES.

Regarding interferon (IFN) alpha, my concern is the potential exacerbation of the psoriatic exanthema, a well-recognized side effect of IFN alpha.

Ioannis Kotsianidis, MD, PhD
Alexandroupolis, Greece

I think we are dealing with the lymphoid variant of hypereosinophilia, which is most likely associated with the dermatologic presentation. We may need to use PCR for the T-cell receptor, or next-generation sequencing if it’s available. Serum IgM may add value in addition to IgE.

He started on steroids with failure treatment on cyclosporine (used in first line), so interferon is a good second-line treatment. Other treatment options are mepolizumab, reslizumab, and benralizumab.

Bassam Francis Matti, MD
Baghdad, Iraq

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