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Profile of serum biomarkers in eosinophilic disorders
EJINME-03110; No of Pages 2 European Journal of Internal Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Profile of serum biomarkers in eosinophilic disorders Keywords: Biomarkers Cytokines Eosinophilia Eosinophilic disorders Hypereosinophilic syndromes
To the Editor The term hypereosinophilia (HE) refers to persistent and marked blood eosinophilia which is documented on two occasions, with or without an additional tissue eosinophilia. The persistence of HE without organ involvements is called hypereosinophilia of undetermined significance (HEUS). Hypereosinophilic syndrome (HES) is defined by blood and/or tissue HE with HE-related organ damage [1]. About 10% of patients with HES is detected with FIP1L1-PDGFRA (F/P) fusion which remains a therapeutic target of tyrosine kinase inhibitor [2]. Churg–Strauss syndrome (CSS) is characterized by eosinophilic vasculitis and blood eosinophilia in a patient with a history of sustained asthma and sinusitis [3]. It is noteworthy, that clinical manifestations and serological findings of these eosinophilic disorders may overlap and differential diagnosis is difficult, especially in patients on steroids. The utility of serum biomarkers in distinguishing between different eosinophiliarelated disorders has rarely been investigated. Fifty six patients with unexplained peripheral blood HE N 1.5 × 109/L at first presentation were included in this study. In total, study group was categorized into 4 cohorts: idiopathic (I) HES (n = 27), HEUS (n = 17), F/P-positive HES (n = 7) and CSS (n = 5) and 68% of them (n = 38) were steroid-naïve at blood sampling. 18 subjects were on steroids at evaluation (IHES-CS = 15 and HEUS-CS = 3). Healthy volunteers (n = 24) without peripheral blood eosinophilia were recruited and serve as controls. Cytokine and chemokine levels were measured in serum using DuoSet ELISA kits for human IL-4, IL-5, soluble (s) IL-5Rα, IL-13, IL17, Thymus and Activation-Related Chemokine (TARC), and eotaxin (R&D Systems, Minneapolis, Minn), according to the manufacturer's instructions. Patients with IHES, F/P-positive HES, and CSS were predominantly male whereas HEUS was more frequently observed in females. Median age at diagnosis was similar between study groups. Patient characteristics were shown in Table 1. Patients with HEUS were asymptomatic by definition. Five patients met criteria for CSS. Neuropathy and pulmonary infiltrates were present in 5 and 2 CSS patients, respectively. They remained steroid-naive at blood sampling. Among the IHES population, the organ involvements were as follows: heart (n = 10), skin (n = 5), gastrointestinal tract
(n = 4), peripheral nerves (n = 3), spleen (n = 3), liver (n = 3), peripheral lymph nodes (n = 2), kidneys (n = 2), joints (n = 2) and venous thrombosis (n = 1). Seven patients had detectable F/P fusion on molecular study. They were treatment naive at evaluation. 55% of IHES and 18% of HEUS subjects were taking steroids at the time of biomarkers evaluation; 11 patients were taking median of 30 mg of prednisone daily (range 20–40) whereas 7 subjects were taking between 5 mg and 20 mg daily (median: 10 mg/daily). Serum IL-4 levels were comparable between subjects with eosinophilia and healthy volunteers. Serum IL-5 levels were elevated in all eosinophilic subjects as compared to healthy volunteers. This was true both for steroid-naive subjects as well as for those on steroids. HEUS subjects had a significantly elevated serum IL-5 level as compared to F/Ppositive HES (p = 0.03). Serum sIL-5Rα levels were comparable between eosinophilic subjects and normal controls. Serum IL-13 levels were elevated in all subjects including normal volunteers. However, the only significant difference was detected between HEUS and normal controls (p = 0.04). Serum eotaxin levels did not significantly differ between studied subgroups. Serum TARC levels were significantly elevated in CSS vs IHES (p = 0.04) and CSS vs F/P-positive HES (p = 0.02). HEUS subjects had higher serum TARC levels as compared to F/P-positive HES (p = 0.01). In the group as a whole serum IL-4 levels positively correlated with serum IgE levels (r = 0.57; p = 0.001). and serum TARC and sIL-5Rα levels correlated with blood eosinophilia (r = 0.42; p = 0.001 and r = 0.32; p = 0.03, respectively). No other correlations have been found. A number of different cytokines and chemokines is involved in eosinophil activation, migration and survival. One should bear in mind that some eosinophilic disorders have overlapping clinical manifestations and differentiating between them is challenging. In our study we try to identify serum biomarkers profile to differentiate subjects within the spectrum of eosinophilic disorders. Moreover, we evaluated the impact of steroids on serum biomarker levels. Subjects with IHES are similar to those with HEUS in terms of laboratory data. Thirty six eosinophilic subjects (28 with IHES and 8 with HEUS) have been compared in terms of serum cytokine levels in a recently published study. No significant differences have been detected between subjects with IHES and HEUS [4]. A broad panel of serum biomarkers have also been tested in subjects with HES and CSS. Serum TARC, IL-8 and eotaxin levels were significantly elevated in eosinophilic patients as compared to healthy controls, but no differences were demonstrated between the eosinophilic subgroups. Of note, steroids did not affect serum biomarkers levels [5]. Serum TARC level correlated with blood eosinophilia and IgE levels in eosinophilic subjects and its level decreased significantly after steroid administration [6]. To our study we recruited 56 eosinophilic patients in whom we measured serum levels of different biomarkers known to be involved in eosinophilopoiesis. Our study has demonstrated that subjects with IHES, HEUS and CSS had similar cytokine profiles. Serum biomarker levels did not differ between patients taking and not taking steroids in a majority of studied eosinophilic
http://dx.doi.org/10.1016/j.ejim.2016.01.008 0953-6205/© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Helbig G, et al, Profile of serum biomarkers in eosinophilic disorders, Eur J Intern Med (2016), http://dx.doi.org/10.1016/ j.ejim.2016.01.008
2
Letter to the Editor
Table 1 Demographic and laboratory data of eosinophilic subjects. Parameter
IHES (n = 27)
HEUS (n = 17)
HES F/P+ (n = 7)
CSS (n = 5)
Age Gender (F/M) WBC (×109/L) AEC (×109/L) ALC (×109/L) Hgb (g/dL) PLT (×109/L) EO BM % IgE (IU/mL) Tryptase (ng/mL) Vitamin B12
61 (13–83) 12/15 17.2 (5.7–52.3) 8.3 (0.1–39) 1.8 (0.8–4.4) 12.9 (8.1–17.7) 248 (31–1320) 36 (14–80) 257 (3.5–24,134) 3.9 (2.2–190) 425 (123–1137)
63 (36–85) 10/7 12.0 (7.2–70.1) 5.5 (0.8–55.4) 2.4 (0.4–5.6) 12.8 (11.4–15.9) 251 (99–350) 34 (14–78) 824 (17–4089) 3.2 (1.8–4.46) 335(182–1431)
58 (27–71) 0/7 24.2 (13.4–175) 14.7 (8.8–164) 2.7 (1.8–5.4) 11.2 (8.2–15.1) 135 (78–226) 46 (17–80) 94.2 (25–888) 21.7 (12.2–31.2) 1200 (288–2000)
56 (49–70) 1/4 31.2 (10.2–102) 21.5 (1.9–92.2) 1.7 (1.2–6.0) 12.2 (9.9–13.2) 512 (283–810) 44 (18–72) 502 (71–662) ND 542 (450–1564)
Legend: [values are provided in median and range]; AEC = absolute eosinophil count; ALC = absolute lymphocyte count; CSS = Churg-Strauss syndrome; EO = eosinophilia; F/P = fip1like1-platelet derived growth factor alpha; HEUS = hypereosinophilia of undetermined significance; Hgb = hemoglobin; IHES = idiopathic hypereosinophilic syndrome; ND = not done; PLT = platelets; WBC = white blood cell.
variants. Detection of elevated serum TARC levels, a chemokine thought to be involved in Th2-mediated diseases and may support for a diagnosis of lymphocytic HES variant [7]. These subjects were found to have serum TARC levels up to 100-fold higher than those with normal IL-5 production and normal controls. Similarly, the detection of an aberrant or clonal T-cell population was associated with elevated serum TARC levels among the subjects with HES and HEUS [4]. However, subjects with allergy and parasitosis had also increase of serum TARC levels [7]. Moreover, TARC levels were elevated in bronchoalveolar lavage fluid of patients with eosinophilic pneumonia, but not in subjects with noneosinophilic lung disorders [8]. Steroids did not affect serum TARC levels in our study and this is in keeping with some previous reports [5,7]. The paucity of subjects with eosinophilic variants seems to be the main limitation of the study. Only multicenter co-operation may allow to recruit a sufficient number of patients and better assess the role of serum biomarkers in diagnosis and monitoring of eosinophilic disorders. Authors' contributions GH: study design, writing the manuscript, statistics TF: cytokine and chemokine analysis, statistics, MH and KWP: study design, data collection, SKK: critical comments and manuscript revision. Conflict of interest The authors declare that they have no conflict of interest. References [1] Valent P, Klion AD, Horny HP, Roufosse F, Gotlib J, Weller PF, et al. Contemporary consensus proposal on criteria and classification of eosinophilic disorders and related syndromes. J Allergy Clin Immunol 2012;130:607–12. [2] Jovanovic JV, Score J, Waghorn K, Cilloni D, Gottardi E, Metzgeroth G, et al. Low dose imatinib mesylate leads to rapid induction of major molecular responses and achievement of complete molecular remission in FIP1L1-PDGFRA-positive chronic eosinophilic leukemia. Blood 2007;109:4635–40. [3] Pagnoux C, Guillevin L. Churg-strauss syndrome: evidence for disease subtypes? Curr Opin Rheumatol 2010;22:21–8.
[4] Chen YYK, Khoury P, Ware JM, Holland-Thomas NC, Stoddard JL, Gurprasad S, et al. Marked and persistent eosinophilia in the absence of clinical manifestations. J Allergy Clin Immunol 2014;133:1195–202. [5] Khoury P, Zagallo P, Talar-Williams C, Santos CS, Dinerman E, Holland NC, et al. Serum biomarkers are similar in Churg–Strauss syndrome and hypereosinophilic syndrome. Allergy 2012;67:1149–56. [6] Dallos T, Heiland GR, Strehl J, Karonitsch T, Gross WL, Moosig F, et al. CCL17/thymus and activation-related chemokine in Churg–Strauss syndrome. Arthritis Rheum 2010;62:3496–503. [7] de Lavareille A, Roufosse F, Schmid-Grendelmeier P, Roumier AS, Schandené L, Cogan E, et al. High serum thymus and activation-regulated chemokine levels in the lymphocytic variant of the hypereosinophilic syndrome. J Allergy Clin Immunol 2002;110:476–9. [8] Miyazaki E, Nureki S, Fukami T, Shigenaga T, Ando M, Ito K, et al. Elevated levels of thymus-and activation-regulated chemokine in bronchoalveolar lavage fluid from patients with eosinophilic pneumonia. Am J Respir Crit Care Med 2002;165:1125–31.
Grzegorz Helbig School of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice, Poland Corresponding author at: Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, 40-032 Katowice, Dabrowski Street 25, Poland. Tel.: +48322591310; fax: +48322554985. E-mail address: [email protected]. Tomasz Francuz School of Medicine in Katowice, Department of Biochemistry, Silesian Medical University, Katowice, Poland Marek Hus Department of Hemato-Oncology, Medical University of Lublin, Lublin, Poland Katarzyna Wiśniewska-Piąty Sławomira Kyrcz-Krzemień School of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice, Poland 6 January 2016 Available online xxxx
Please cite this article as: Helbig G, et al, Profile of serum biomarkers in eosinophilic disorders, Eur J Intern Med (2016), http://dx.doi.org/10.1016/ j.ejim.2016.01.008
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Profile of serum biomarkers in eosinophilic disorders Keywords: Biomarkers Cytokines Eosinophilia Eosinophilic disorders Hypereosinophilic syndromes
To the Editor The term hypereosinophilia (HE) refers to persistent and marked blood eosinophilia which is documented on two occasions, with or without an additional tissue eosinophilia. The persistence of HE without organ involvements is called hypereosinophilia of undetermined significance (HEUS). Hypereosinophilic syndrome (HES) is defined by blood and/or tissue HE with HE-related organ damage [1]. About 10% of patients with HES is detected with FIP1L1-PDGFRA (F/P) fusion which remains a therapeutic target of tyrosine kinase inhibitor [2]. Churg–Strauss syndrome (CSS) is characterized by eosinophilic vasculitis and blood eosinophilia in a patient with a history of sustained asthma and sinusitis [3]. It is noteworthy, that clinical manifestations and serological findings of these eosinophilic disorders may overlap and differential diagnosis is difficult, especially in patients on steroids. The utility of serum biomarkers in distinguishing between different eosinophiliarelated disorders has rarely been investigated. Fifty six patients with unexplained peripheral blood HE N 1.5 × 109/L at first presentation were included in this study. In total, study group was categorized into 4 cohorts: idiopathic (I) HES (n = 27), HEUS (n = 17), F/P-positive HES (n = 7) and CSS (n = 5) and 68% of them (n = 38) were steroid-naïve at blood sampling. 18 subjects were on steroids at evaluation (IHES-CS = 15 and HEUS-CS = 3). Healthy volunteers (n = 24) without peripheral blood eosinophilia were recruited and serve as controls. Cytokine and chemokine levels were measured in serum using DuoSet ELISA kits for human IL-4, IL-5, soluble (s) IL-5Rα, IL-13, IL17, Thymus and Activation-Related Chemokine (TARC), and eotaxin (R&D Systems, Minneapolis, Minn), according to the manufacturer's instructions. Patients with IHES, F/P-positive HES, and CSS were predominantly male whereas HEUS was more frequently observed in females. Median age at diagnosis was similar between study groups. Patient characteristics were shown in Table 1. Patients with HEUS were asymptomatic by definition. Five patients met criteria for CSS. Neuropathy and pulmonary infiltrates were present in 5 and 2 CSS patients, respectively. They remained steroid-naive at blood sampling. Among the IHES population, the organ involvements were as follows: heart (n = 10), skin (n = 5), gastrointestinal tract
(n = 4), peripheral nerves (n = 3), spleen (n = 3), liver (n = 3), peripheral lymph nodes (n = 2), kidneys (n = 2), joints (n = 2) and venous thrombosis (n = 1). Seven patients had detectable F/P fusion on molecular study. They were treatment naive at evaluation. 55% of IHES and 18% of HEUS subjects were taking steroids at the time of biomarkers evaluation; 11 patients were taking median of 30 mg of prednisone daily (range 20–40) whereas 7 subjects were taking between 5 mg and 20 mg daily (median: 10 mg/daily). Serum IL-4 levels were comparable between subjects with eosinophilia and healthy volunteers. Serum IL-5 levels were elevated in all eosinophilic subjects as compared to healthy volunteers. This was true both for steroid-naive subjects as well as for those on steroids. HEUS subjects had a significantly elevated serum IL-5 level as compared to F/Ppositive HES (p = 0.03). Serum sIL-5Rα levels were comparable between eosinophilic subjects and normal controls. Serum IL-13 levels were elevated in all subjects including normal volunteers. However, the only significant difference was detected between HEUS and normal controls (p = 0.04). Serum eotaxin levels did not significantly differ between studied subgroups. Serum TARC levels were significantly elevated in CSS vs IHES (p = 0.04) and CSS vs F/P-positive HES (p = 0.02). HEUS subjects had higher serum TARC levels as compared to F/P-positive HES (p = 0.01). In the group as a whole serum IL-4 levels positively correlated with serum IgE levels (r = 0.57; p = 0.001). and serum TARC and sIL-5Rα levels correlated with blood eosinophilia (r = 0.42; p = 0.001 and r = 0.32; p = 0.03, respectively). No other correlations have been found. A number of different cytokines and chemokines is involved in eosinophil activation, migration and survival. One should bear in mind that some eosinophilic disorders have overlapping clinical manifestations and differentiating between them is challenging. In our study we try to identify serum biomarkers profile to differentiate subjects within the spectrum of eosinophilic disorders. Moreover, we evaluated the impact of steroids on serum biomarker levels. Subjects with IHES are similar to those with HEUS in terms of laboratory data. Thirty six eosinophilic subjects (28 with IHES and 8 with HEUS) have been compared in terms of serum cytokine levels in a recently published study. No significant differences have been detected between subjects with IHES and HEUS [4]. A broad panel of serum biomarkers have also been tested in subjects with HES and CSS. Serum TARC, IL-8 and eotaxin levels were significantly elevated in eosinophilic patients as compared to healthy controls, but no differences were demonstrated between the eosinophilic subgroups. Of note, steroids did not affect serum biomarkers levels [5]. Serum TARC level correlated with blood eosinophilia and IgE levels in eosinophilic subjects and its level decreased significantly after steroid administration [6]. To our study we recruited 56 eosinophilic patients in whom we measured serum levels of different biomarkers known to be involved in eosinophilopoiesis. Our study has demonstrated that subjects with IHES, HEUS and CSS had similar cytokine profiles. Serum biomarker levels did not differ between patients taking and not taking steroids in a majority of studied eosinophilic
http://dx.doi.org/10.1016/j.ejim.2016.01.008 0953-6205/© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Helbig G, et al, Profile of serum biomarkers in eosinophilic disorders, Eur J Intern Med (2016), http://dx.doi.org/10.1016/ j.ejim.2016.01.008
2
Letter to the Editor
Table 1 Demographic and laboratory data of eosinophilic subjects. Parameter
IHES (n = 27)
HEUS (n = 17)
HES F/P+ (n = 7)
CSS (n = 5)
Age Gender (F/M) WBC (×109/L) AEC (×109/L) ALC (×109/L) Hgb (g/dL) PLT (×109/L) EO BM % IgE (IU/mL) Tryptase (ng/mL) Vitamin B12
61 (13–83) 12/15 17.2 (5.7–52.3) 8.3 (0.1–39) 1.8 (0.8–4.4) 12.9 (8.1–17.7) 248 (31–1320) 36 (14–80) 257 (3.5–24,134) 3.9 (2.2–190) 425 (123–1137)
63 (36–85) 10/7 12.0 (7.2–70.1) 5.5 (0.8–55.4) 2.4 (0.4–5.6) 12.8 (11.4–15.9) 251 (99–350) 34 (14–78) 824 (17–4089) 3.2 (1.8–4.46) 335(182–1431)
58 (27–71) 0/7 24.2 (13.4–175) 14.7 (8.8–164) 2.7 (1.8–5.4) 11.2 (8.2–15.1) 135 (78–226) 46 (17–80) 94.2 (25–888) 21.7 (12.2–31.2) 1200 (288–2000)
56 (49–70) 1/4 31.2 (10.2–102) 21.5 (1.9–92.2) 1.7 (1.2–6.0) 12.2 (9.9–13.2) 512 (283–810) 44 (18–72) 502 (71–662) ND 542 (450–1564)
Legend: [values are provided in median and range]; AEC = absolute eosinophil count; ALC = absolute lymphocyte count; CSS = Churg-Strauss syndrome; EO = eosinophilia; F/P = fip1like1-platelet derived growth factor alpha; HEUS = hypereosinophilia of undetermined significance; Hgb = hemoglobin; IHES = idiopathic hypereosinophilic syndrome; ND = not done; PLT = platelets; WBC = white blood cell.
variants. Detection of elevated serum TARC levels, a chemokine thought to be involved in Th2-mediated diseases and may support for a diagnosis of lymphocytic HES variant [7]. These subjects were found to have serum TARC levels up to 100-fold higher than those with normal IL-5 production and normal controls. Similarly, the detection of an aberrant or clonal T-cell population was associated with elevated serum TARC levels among the subjects with HES and HEUS [4]. However, subjects with allergy and parasitosis had also increase of serum TARC levels [7]. Moreover, TARC levels were elevated in bronchoalveolar lavage fluid of patients with eosinophilic pneumonia, but not in subjects with noneosinophilic lung disorders [8]. Steroids did not affect serum TARC levels in our study and this is in keeping with some previous reports [5,7]. The paucity of subjects with eosinophilic variants seems to be the main limitation of the study. Only multicenter co-operation may allow to recruit a sufficient number of patients and better assess the role of serum biomarkers in diagnosis and monitoring of eosinophilic disorders. Authors' contributions GH: study design, writing the manuscript, statistics TF: cytokine and chemokine analysis, statistics, MH and KWP: study design, data collection, SKK: critical comments and manuscript revision. Conflict of interest The authors declare that they have no conflict of interest. References [1] Valent P, Klion AD, Horny HP, Roufosse F, Gotlib J, Weller PF, et al. Contemporary consensus proposal on criteria and classification of eosinophilic disorders and related syndromes. J Allergy Clin Immunol 2012;130:607–12. [2] Jovanovic JV, Score J, Waghorn K, Cilloni D, Gottardi E, Metzgeroth G, et al. Low dose imatinib mesylate leads to rapid induction of major molecular responses and achievement of complete molecular remission in FIP1L1-PDGFRA-positive chronic eosinophilic leukemia. Blood 2007;109:4635–40. [3] Pagnoux C, Guillevin L. Churg-strauss syndrome: evidence for disease subtypes? Curr Opin Rheumatol 2010;22:21–8.
[4] Chen YYK, Khoury P, Ware JM, Holland-Thomas NC, Stoddard JL, Gurprasad S, et al. Marked and persistent eosinophilia in the absence of clinical manifestations. J Allergy Clin Immunol 2014;133:1195–202. [5] Khoury P, Zagallo P, Talar-Williams C, Santos CS, Dinerman E, Holland NC, et al. Serum biomarkers are similar in Churg–Strauss syndrome and hypereosinophilic syndrome. Allergy 2012;67:1149–56. [6] Dallos T, Heiland GR, Strehl J, Karonitsch T, Gross WL, Moosig F, et al. CCL17/thymus and activation-related chemokine in Churg–Strauss syndrome. Arthritis Rheum 2010;62:3496–503. [7] de Lavareille A, Roufosse F, Schmid-Grendelmeier P, Roumier AS, Schandené L, Cogan E, et al. High serum thymus and activation-regulated chemokine levels in the lymphocytic variant of the hypereosinophilic syndrome. J Allergy Clin Immunol 2002;110:476–9. [8] Miyazaki E, Nureki S, Fukami T, Shigenaga T, Ando M, Ito K, et al. Elevated levels of thymus-and activation-regulated chemokine in bronchoalveolar lavage fluid from patients with eosinophilic pneumonia. Am J Respir Crit Care Med 2002;165:1125–31.
Grzegorz Helbig School of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice, Poland Corresponding author at: Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, 40-032 Katowice, Dabrowski Street 25, Poland. Tel.: +48322591310; fax: +48322554985. E-mail address: [email protected]. Tomasz Francuz School of Medicine in Katowice, Department of Biochemistry, Silesian Medical University, Katowice, Poland Marek Hus Department of Hemato-Oncology, Medical University of Lublin, Lublin, Poland Katarzyna Wiśniewska-Piąty Sławomira Kyrcz-Krzemień School of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice, Poland 6 January 2016 Available online xxxx
Please cite this article as: Helbig G, et al, Profile of serum biomarkers in eosinophilic disorders, Eur J Intern Med (2016), http://dx.doi.org/10.1016/ j.ejim.2016.01.008