Loefflers syndrome differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]

Overview

Loeffler syndrome must be differentiated from other diseases that cause pulmonary eosinophilia, such as Churg-Strauss, drug and toxin-induced eosinophilic lung diseases, other helminthic and fungal infection related eosinophilic lung diseases, and nonhelminthic infections such as Coccidioidomycosis, and Mycobacterium tuberculosis.

Differentiating Loeffler syndrome from other pulmonary eosinophilia syndromes on the basis of etiology.

Diseases		Clinical manifestations						Para-clinical findings							Gold standard	Additional findings
		Symptoms			Physical examination
								Lab Findings			Imaging			Histopathology
						Physical exam 2	Physical exam 3	Increased Eosinophil count (High)	Increased Eosinophil count (Mild to moderate)	ELISA	CXR	Imaging 2	Imaging 3
Helminthic and fungal infection-related eosinophilic lung diseases	Transpulmonary passage of larvae (Loffler's syndrome)	Cough Sputum production Wheezing Fever									Round or oval opacities (several millimeters to several centimeters) In both lungs Generally present when blood eosinophilia exceeds 10% Migratory May become confluent in perihilar areas Generally clear spontaneously					Ascaris lumbricoides Hookworms such as: Ancylostoma duodenale Necator americanus) Strongyloides stercoralis
	Tropical pulmonary eosinophilia							40 to 70 percent								Wuchereria bancrofti Brugia malayi
	Allergic bronchopulmonary aspergillosis								*
	Heavy hematogenous seeding with helminths	depends on the organism for example: periorbital edema, myositis, and eosinophilia (Trichinellosis)						*	*	Trichinellosis: will be positive 2-8 weeks after infection Strongyloides: ELISA is generally positive while stool examination is often negative.	Strongyloides: diffuse ground glass opacities					Ascarids and hookworms Trichinellosis Disseminated strongyloidiasis Cutaneous and visceral larva migrans Schistosomiasis Prior treatment with glucocorticoids may be a risk factor.
	Pulmonary parenchymal invasion							Eosinophilia is prominent in the early stages of disease but minimal with established disease		Useful in later infection with Paragonimus	Nodular with surrounding areas of ground glass Peripheral Common in the mid- and lower lung zones			Finding eggs in the sputum or bronchoalveolar lavage fluid		Helminths such as paragonimiasis
Nonhelminthic infections	Coccidioidomycosis
	Mycobacterium tuberculosis
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)								*
Drug- and toxin-induced eosinophilic lung diseases									*							Nonsteroidal antiinflammatory drugs Phenytoin L-tryptophan Antibiotics (nitrofurantoin, minocycline, sulfonamides, ampicillin, daptomycin)
	Acute eosinophilic pneumonia
	Chronic eosinophilic pneumonia							≥40 percent
	Idiopathic acute eosinophilic pneumonia							≥25 percent
Diseases		Symptom 1	Symptom 2	Symptom 3	Physical exam 1	Physical exam 2	Physical exam 3	Increased Eosinophil count (High)	Increased Eosinophil count (Mild to moderate)	ELISA	Imaging 1	Imaging 2	Imaging 3	Histopathology	Gold standard	Additional findings
	Sarcoidosis								*
	Pulmonary Langerhans cell histiocytosis (Histiocytosis X)								*
	Idiopathic pulmonary fibrosis							<10 percent
	Differential Diagnosis 7