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\begin{document}

\title{TUBERCULOSIS MANIFESTING WITH SIGNIFICANT PERIPHERAL EOSINOPHILIA: A
CASE REPORT AND REVIEW OF LITERATURE}



\author[1]{Abhiram Rao Damera}%
\author[2]{Prakash  Gupta}%
\author[3]{Shaheer Farooqi}%
\author[4]{Vivek Sanker}%
\author[5]{Arpita Mariam Mathews}%
\author[6]{Shreya Pampati}%
\author[1]{Manoj Allala}%
\author[7]{Tirth Dave}%
\affil[1]{MediCiti Institute of Medical Sciences}%
\affil[2]{Virgen Milagrosa University Foundation}%
\affil[3]{Ziauddin Medical College}%
\affil[4]{Noorul Islam Institute of Medical Science and Research Foundation Medicity}%
\affil[5]{Mount Zion Medical College}%
\affil[6]{Kamineni Institute of Medical Sciences}%
\affil[7]{Bukovinian State Medical University}%


\vspace{-1em}



  
  \date{May 29, 2024}


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\sloppy


\textbf{INTRODUCTION:}

Tuberculosis (TB) is still one of the most prevalent infections,
especially in the developing world. The World Health Organisation (WHO)
estimates that there are 8 million new cases annually {[}1,2{]}. Cough,
sputum with or without haemoptysis, fever, and constitutional symptoms
are the hallmark manifestations of an active tuberculosis infection. In
patients with pulmonary TB, an increase in haemoglobin levels is
regarded as an indicator of a positive response to treatment.
Furthermore, Omar et al. found that a fall in platelet count, white
blood cell (WBC) count, and erythrocyte sedimentation rate (ESR) were
strong indications of clinical response {[}3{]}. Despite the possibility
of an increase in white blood cells (WBC), which results in lymphocyte
predominance, in clinical practice, eosinophilia is a usual finding that
is self-limiting in moderate cases, but it is exceedingly infrequent in
TB {[}4,5{]}.

Many allergic, viral, and neoplastic conditions may produce peripheral
blood eosinophilia, necessitating a variety of examinations and
subsequent therapy. Common causes of eosinophilia in children include
infections with helminthic parasites, allergic diseases, malignancies,
and adverse drug reactions {[}1,6{]}. One of the primary goals of the
early evaluation is to identify an underlying cause that needs specific
therapy. Even though difficulties linked with eosinophilia are more
prevalent in individuals with higher eosinophil counts
(\textgreater{}1500 eosinophils/uL), the peripheral blood eosinophil
count does not accurately assess the risk of organ damage in each
patient. A patient with modest peripheral blood eosinophilia may also
have significant eosinophil organ involvement. Normal eosinophil counts
in the human blood range between 0-350/mm3. This quantity accounts for
between 1 and 3\% of the differential leukocyte count {[}7{]}. Most
reports of eosinophilia in tuberculosis describe local eosinophilia as
opposed to peripheral eosinophilia {[}8{]}. To the best of our
knowledge, reported cases are very rare. As a consequence, we describe
one case of TB with considerable peripheral eosinophilia and the
treatment outcome.

\textbf{CASE PRESENTATION:}

A 9-year-old male child was presented to the paediatrics department with
his mother, reporting symptoms of fever and persistent cough of one
month duration, associated with acute respiratory distress. The fever
was sudden in onset, low grade, and associated with chills. There were
no aggravating factors, and it was alleviated through the use of
medication. The child was active during the period between febrile
episodes. The cough was productive, not associated with aggravating
factors, and not relieved by medications. A history of weight loss and
loss of appetite were present. There were no similar complaints among
his family members.

The patient had a past medical history of fever and myalgia, which was
diagnosed as typhoid fever. He had been given all the scheduled
immunisations, including BCG, without experiencing any significant
adverse effects.

On examination, the patient was thin-built, not active, and oriented to
time, place, and person. The patient was tachypnoeic (38/min), afebrile,
and hemodynamically stable. Cervical lymph nodes were palpable,
nontender, firm, and 2-3 in number on both sides. A chest examination
revealed bilateral crepitations in the mammary, infra-mammary, axillary,
and infra-axillary regions. Other systems revealed no abnormalities.

Initial blood investigations~\textbf{(Table 1)} ~revealed a total
leucocyte count (TLC) of 36,000 cells per cubic mm, a differential count
of neutrophils of 11\%, lymphocytes (13\%), and eosinophils of 72\%. A
peripheral smear showed normocytic normochromic blood with eosinophilic
leucocytosis. The absolute eosinophil count (AEC) was 25,920 cells per
cubic mm. Liver function tests (LFT) and renal function tests (RFT) were
normal. Hepatitis B surface antigen, anti-hepatitis C antibody, and
Human Immunodeficiency Virus (HIV-1 and HIV-2) ELISA results were all
negative. Mantoux's skin test was negative. He underwent additional
tests, including a peripheral smear for microfilaria, the Widal test,
the Dengue NS1 antigen test, toxoplasmosis serology, and sputum fungal
staining, all of which were negative. Blood, urine, and stool cultures
were also negative. The bone marrow aspiration performed to rule out
eosinophilic leukaemia showed a negative result.

A chest X-ray revealed diffuse nodular calcifications in bilateral lungs
involving all zones~\textbf{(Figure 1)} . High-resolution computed
tomography (HRCT) chests show multiple tiny (2--3 mm) centrilobular and
peri-broncho-vascular branching nodular densities noted scattered
diffusely and equally in bilateral lungs, both in the upper and lower
lobes~\textbf{(Figure 2)} . Ultrasound (US) of the chest showed mild
left-sided pleural effusion with lung consolidation and collapse. The US
neck detected sub-centimetrically enlarged cervical lymph nodes (7-8
mm). ZN stain and cartridge-based nucleic acid amplification test
(CBNAAT) tests on sputum samples produced normal results.

The child was initially started on amoxicillin and clavulanic acid (a
combination antibiotic). Due to his raised eosinophil count, the child
was given diethylcarbamazine. Other symptomatic and supportive treatment
was given with intravenous fluids, pantoprazole, paracetamol, Lactic
Acid Bacillus (a probiotic), and nebulisations with 3\% normal saline
and levo salbutamol. Chest physiotherapy and spirometric exercises were
advised. In view of radiologically diagnosed pulmonary tuberculosis, the
patient's regimen shifted to anti-tubercular therapy (ATT) with a
fixed-dose combination of isoniazid, rifampicin, pyrazinamide, and
ethambutol with pyridoxine. Complaints of coughing and difficulty
breathing subsided at the time of discharge. At one-month follow-up, his
eosinophil counts returned to normal levels.\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{Test}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{Result}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{Units}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{Normal Range}\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\textbf{Method}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Hemoglobin\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
11.6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
gm/dl\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
11.5-15.5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Colorimetric\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Total Count\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{36,000}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
cells/cu mm\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5000-13,000\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Impedance\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Neutrophils\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{11}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
40-80\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Light Microscopy\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Lymphocytes\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{13}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20-40\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Light Microscopy\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Eosinophils\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{72}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
01-06\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Light Microscopy\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Monocytes\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
04\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
02-10\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Light Microscopy\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Basophils\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
00\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0-2\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Light Microscopy\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Packed Cell Volume (PCV)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
35.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Vol \%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
35-45\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Calculation\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Mean Corpuscular Volume (MCV)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
87.5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Fl\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
77-95\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Calculation\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Mean Corpuscular Haemoglobin (MCH)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
28.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Pg\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
25-33\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Calculation\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Mean Corpuscular Haemoglobin Concentration (MCHC)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
32.5\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\%\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
31.0-37.0\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Calculation\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Red Blood Cell count\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4.08\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
millions/cu mm\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4.0-5.2\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Impedance\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Platelet count\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
lakhs/cu mm\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.4-4.1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Impedance\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 1: Routine blood investigations on admission}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textsuperscript{~}

\textbf{Figure 1: Chest X-ray showing diffuse nodular calcifications in
both lungs, involving all zones}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2: HRCT showing~Numerous~tiny~(2--3 mm) nodules in both
lungs, with branching patterns in both~the~upper and lower lobes.}

\textbf{DISCUSSION:}

The most prevalent reasons for increased eosinophil count are parasitic
infections, allergy/atopy, urticaria, eczema, allergic rhinitis,
angioneurotic oedema, reactive eosinophilia subsequent to T-cell
lymphoma, acute leukaemia, B-cell lymphoma, eosinophilic leukaemia,
allergic drug reactions, idiopathic hyper-eosinophilic syndrome, and
collagen vascular diseases such as rheumatoid arthritis, eosinophilic
fasciitis, or allergic angiitis {[}9{]}.

Although TB is not a well-known cause of eosinophilia in the medical
literature, it was identified in our case. Based on current evidence,
there have been few reported instances of this phenomenon in recent
years. Flores et al. described a similar case of peripheral blood
eosinophilia and TB, which included symptoms such as lethargy, weight
loss, and lymphadenopathy and was confirmed by a lymph node biopsy that
revealed a granulomatous lesion {[}10{]}. Gill et al. reported a case of
abdominal tuberculosis with peripheral eosinophilia. The patient was
diagnosed with abdominal tuberculosis based on a histopathological
examination of peritoneal tissue {[}8{]}. Similarly, Garg et al.
reported a case of peripheral blood eosinophilia and TB, which included
symptoms such as cough, generalized weakness, and significant weight
loss and was confirmed by endoscopic bronchial ultrasound-guided
fine-needle aspiration of the mediastinal lymph node that revealed
acid-fast bacilli {[}5{]}.

Ray et al. proposed that after experiencing an early hypersensitive
reaction to the Mycobacterium antigen, susceptible people can develop
florid tropical pulmonary eosinophilia {[}11{]}. IL-5 has been shown to
be the main cytokine driving the development of peripheral eosinophilia
in people with pulmonary TB. The release of toxic eosinophil products is
closely associated with tissue pathology. Examples of such by-products
are eosinophil cationic protein, major basic protein, and
eosinophil-derived neurotoxin. Potentially, the emission of reactive
oxygen species may cause tissue injury {[}12{]}. The normal range of
eosinophils in blood is between 0.0 and 6.0 \%, and between 30 and 350
is the typical range for the AEC. AEC between 0.5 and 1.0 x109/L (SI
units) or 0.5 and 1.0 x103 cells/microliter (conventional units) is
considered to be mild blood eosinophilia, whereas AEC greater than or
equal to 1.5 x109/L is considered to be hyper-eosinophilia {[}13{]}. Our
patient presented with an AEC of 70\%, accounting for 25,920 cells, and
a TLC of 36,000.

Hsu et al. reported that patients undergoing peritoneal dialysis had
modest peripheral blood and peritoneal fluid eosinophilia. The
eosinophilia persisted despite the cessation of dialysis, but it
disappeared following the initiation of anti-tuberculous treatment
{[}14{]}. Similarly, Haftu et al. reported a rare case of hepatic TB
with significant peripheral eosinophilia {[}15{]}. Our patient's imaging
results aided in clinching the diagnosis. Further evidence supporting
the link between TB and peripheral eosinophilia is the patient's
positive clinical response to anti-TB therapy with Ethambutol,
Rifampicin, Isoniazid, and Pyrazinamide for the initial two months,
followed by Rifampicin and Isoniazid for the next four months
(2ERHZ/4RH). Patients with peripheral eosinophilia should have TB
considered as a differential diagnosis, particularly after more
prevalent reasons have been ruled out.

A few similar cases in the literature are described below~\textbf{(Table
2)} :\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Author\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Case age/ Sex\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Sign/symptoms\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Radiographic findings\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Laboratory Findings\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Treatment plan\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Outcome\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Flores et al, 1983 {[}1{]}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
61/M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Skin lesions, mild splenomegaly, cervical, axillary, and inguinal
lymphadenopathy, fever, weakness, fatigue, and weight loss.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Abdominal Computed Tomography (CT) revealed retroperitoneal
lymphadenopathy.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-White Blood cell (WBC), 8,200/cu mm, 26\% neutrophils, 12\%
lymphocytes, 62\% eosinophils; -Biopsies of skin lesions, liver, and
lymph nodes revealed caseating granulomas with Langhans' giant cells and
eosinophils. -A Ziehl-Neelsen (ZN) stain found acid-fast bacteria.
\textbf{-A needle-aspirated bone marrow specimen showed eosinophil
infiltration}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Isoniazid, Rifampin, Ethambutol, Streptomycin\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
The patient's health improved quickly.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Gill et al, 1940 {[}8{]}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
19/M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Sharp chest pain, dry cough, sweating, upper abdominal discomfort,
fever, and tachycardia.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Right-sided pleural effusion\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
- A chest fluid sample was cloudy and blood-stained, and a differential
count indicated 80\% eosinophil polymorphonuclear leukocytes. -Blood
eosinophils 14 \%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Laparotomy\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
The patient died eleven weeks after admission as his health
worsened.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Hsu et al, 2000 {[}14{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
66/F\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Chronic renal failure, bilateral neck mass growth (1--3 cm) and
malaise\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
CT showed numerous lymphadenopathies and substantial central necrosis on
both neck sides.\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Peritoneal eosinophilia (54--85\%) and peripheral eosinophilia
(7--12\%), pus-like material with unidentified non-fermentative
Gram-negative bacilli in the biopsy.\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
About 2 weeks later, her peripheral and peritoneal fluid eosinophilia
subsided.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Garg et al, 2017 {[}5{]}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
68/F\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Cough, fatigue, weight loss, skinny, and pale\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
A contrast-enhanced CT of the chest and abdomen showed enlarged
non-necrotic mediastinal lymph nodes with chronic liver disease
features.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-Neutrophils 41\%, lymphocytes 27\%, and eosinophils 32\%.
-Needle-aspirated bone marrow and biopsies showed increased eosinophilic
-Endoscopic bronchial ultrasound-guided fine-needle aspiration of
mediastinal lymph nodes showed tubercular inflammation with
bacilli-positive acid-fast stain.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Eosinophil counts normalized within a week.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Haftu et al, 2020 {[}15{]}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9/F\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Right upper quadrant stomach ache, decreased appetite, vomiting, weight
loss, lethargy, and low-grade intermittent fever\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-Abdominal Ultrasound (US) shows hepatomegaly with aberrant echo pattern
and cystic change -Liver CT indicates several cystic and tiny daughter
cysts as a connecting hypoechoic mass-like lesion\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-Leucocytosis with severe eosinophilia with 50\% -The biopsy showed
partially encapsulated hepatocyte lobules with many epithelioid
granulomas, large cells, necrosis, and micro abscesses and chronic
inflammatory cells, mostly lymphocytes and eosinophils, confirming Liver
TB.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
After six months of Anti-Tubercular Therapy (ATT), the patient was
symptom-free, gained 5 kg, and with normal lab findings.\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2: List of similar cases published in literature}

\textbf{CONCLUSION:}

The diagnostic process begins with a thorough history and physical
examination. When collecting a patient's history, it is important to ask
about travel history as well as any diseases or conditions related to
collagen vascular tissue, changes in immunological function, medication
use, or blockage of the airway. Even with infectious disorders, the
ultimate diagnosis will always depend on how well the patient responds
to therapy. In light of these findings, we believe that further studies
are required to determine the pathophysiology of severe eosinophilia in
TB and to identify this condition as a potential causal factor.

\textbf{CONFLICTS OF INTEREST:}

None declared.

\textbf{AUTHOR CONTRIBUTION:}

All the authors contributed equally in drafting, editing, revising and
finalizing the case report.

\textbf{ETHICAL APPROVAL:}

The ethical approval was not required for the case report as per the
country's guidelines.

\textbf{CONSENT:}

Written informed consent was obtained from the patient to publish this
report.

\textbf{DATA AVAILABILITY STATEMENT:}

The data that support the findings of this article are available from
the corresponding author upon reasonable request.

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