Textbook of Radiology and Imaging David Sutton

7th Edition, Vol.2, Section 5 . Chapter 40. Page 1311

EOSINOPHILIC
GRANULOMA

Presented By : Rizki Amallia

Consultant : dr. Amri Wicaksono P.,Sp.Rad

Presentation Date : Monday, April 14th 2019

Chapter 41. Disorders of The Lymphoreticular
System and Other Haematopoietic Disorders
 Disease primarily involving red blood cells
 Disease primarily involving white blood cells
 Disease of the lymphoreticular system
- Malignant lymphomas
- Burkitt’s tumour
- Mastocytoma
- Plasmacytoma
- Multiple Myelomatosis
- POEMS syndrome

- Eosinophilic granuloma
- Hand-Schüller-Christian disease
- Letterer-Siwe disease
- Gaucher’s disease
- Niemann-Pick Disease
 INTRODUCTION 1,2,3,4

The term “Eosinophilic Granuloma”  was introduced by Lichtenstein & Jaffe in 1940

Eosinophilic Granuloma (EG) is one of the rarest benign tumor-like disorder, characterized
by clonal proliferation of antigen-presenting mononuclear cells of dendritic origin known as
Langerhans

EG is one of the 3 described manifestations of Langerhan’s cell histiocytosis (LCH) /

Langerhans cell granulomatosis / histiocytosis X. The 2 other forms  the Letterer-Siwe
disease & the Hand-Schüller-Christian disease
 EPIDEMIOLOGY 1,2,3,7,8

1 2 3
It represents < 1% of The incidence is Most commonly occurs in
all tumorlike lesions approximately children (80% of afflicted <
of bone. 1:1.500.000 people 20 years of age). Observed
in adolescents & young
adults

4 5 6
Male : female = 2:1 Rarely seen among The most common
blacks subtype, accounting for
about 70% of LCH cases
 LOCATION
Any bone may be affected. The usual sites  calvaria,
pelvis, vertebra, mandibula, costae, clavicle & long bones
(femur, tibia, humerus) 9,10

In the head & neck region  frequently affect soft

tissues adjacent to the involved bones 11

In the vertebra  accounts for 6.5–25 % of all spinal

bone tumors. The thoracic level is most commonly
affected, followed by the lumbar & cervical spine 2,12

In the long bones  the diaphysis is most commonly

affected (58%), followed by the metaphysis 9,10

Lesion is usually monostotic, but polyostotic

involvement has been reported in 10% of patients. The
growth plate acts as a barrier to lesion invasion 5,10

Rarely other organs like lungs, stomach & liver are

involved. Still more rare is the involvement of the skin

Kang O, Singh G. Langerhans cell hitiocytosis (skeletal manifestation).

Http://radiopaedia.org/cases/16462/studied/16243?lang=us&referrer=%2Farticles%2Flangerhans-cel-histiocytosis-
skeletal-manifestations
 ETIOLOGY 12,13,14
 The etiology  remains unclear

 While theories have included 

A disorder of immune regulation (an immunological dysfunction including an increase of certain

cytokines ex. interleukin-1 & interleukin-10)

A neoplastic process

Infections of viruses (ex. Epstein-Barr, human herpes virus-6) even bacteria have been postulated

Genetic causes with autosomal recessive inheritance, activating somatic BRAF mutations (gene
that encodes a protein)
 PATHOGENESIS 1,12,15

The pathogenesis  is not completely understood

EG  Histiocytic disorders that localizes to bone  histiocytosis cells (Langerhans

cell) induce bone resorption through their ability to secrete locally tissue-lytic factors
such as interleukins (IL-1) & prostaglandins (PG-E2), even damage surrounding tissues
 Agranulocytes
Monocytes

Group of
Histiocytes

APC

Macrophages Dendritic Cells

Lung  Alveolar
Spleen  Veiled cell
Kidney  Mesangial
Thymus  Interdigitating cell
Brain  Microglial
Epidermis  Langerhans
Liver  Kupffer

http://id.m.Wikipedia.org/wiki/Sel_dendritik
Around blood vessels, lymph nodes, lung Nestle FO. Skin immune sentinels in health and disease.
Nature Reviews Immunology, 2009(9): 679-691
 Langerhans
Cell
Histiocytosis
(LCH)

Proliferation of An abundance of An abundance of

Langerhans cell Lymphocytes Eosinophils

http://siteman.wusti.edu/glossary/cdr0000045765/
 Symptoms of the disease
are variable & non-specific

Skeletal involvement (pain,

localized swelling, limping
with pelvic or lower extremity
involvement, pathological
May be discovered as an fracture
incidental radiographic finding
Vertebral involvement
A CLINICAL (localized or diffuse back pain,
in routine radiographic Symp kyphotic posture,
Symp
examination, FINDINGS tomatic radiculopathy)
tomatic
screening for other 1,2,8,9
Systemic symptoms (general
medical problems or in malaise, on occasion fever)
traumatic conditions (e.g.
head injury)
Skin lesions are rare

 Affected children normally present with an acute onset of neck pain, a reactive
torticollis & stiffness without history of trauma. Denaro et al. reported an incidence of
torticollis in 71% of their 7 pediatric patients with an EG of the cervical spine
 LABORATORY FINDINGS 9,11

Clinical Pathology : are usually non-specific, a moderate rise in erythrocyte sedimentation rate the
(average about 12 mm in one hour), mild leukocytosis

Anatomical Pathology : biopsy  Langerhans cells with increased eosinophils & mixed inflammatory
cells.

Electron microscope  Birbeck granules Langerhans cell 200 - 400 nm  varies with greater
prominence in early lesions

Sharma P. Langerhan’s histiocytosis. Https://medium.com/@UshieCharmz/Langerhans-histiocytosis-12276a0bf2b4

 GROSS PICTURE 11,12
The area of destroyed bone is replaced by a soft tissue (reddish-brown in colour), & over time the lesions
become fibrous & grayish

Fig. Gross photograph: greyish-brown soft tissue

fragments with teeth & bony chips
 HISTOPATHOLOGY 1,2

Characterized by an accumulation of
Langerhan’s histiocytes,

Variably admixed with eosinophils,

Round or oval nuclei

An eosinophil under the microscope. The purple area is the nucleus.

The pink polka-dot granules contain chemicals of inflammation
& give the cell its name as Eosin dye is pink.
(Photo Credit: CDC Public Health Image Library)
 DIAGNOSIS 9

CT-guided biopsy  effective for

histological diagnosis, with low morbidity
& a diagnostic accuracy of 70–100 %

Renonce HT, Mangunsudirdjo S, Soeripto, Bras J. Cranial unifocal langerhans cell histiocytosis in a female child: a difficult case with S-100 and CD1a immunonegativity.
J Med SSccii, 2011 (43) : 2 : 150-160
IMAGING MODALITIES

Plain
Radio USG
graph

CT
MRI
Scan

EG lesions have varied & nonspecific imaging

 ‘the great imitator/mimicker’
 PLAIN RADIOGRAPH 6,8,9,13
Characterized by the presence of erosive & destructive bony lesions

Around 70% of them are solitary  varying sizes between 1-3 cm

Multiple lytic lesions can occur in the same bone or in multiple bones

In the active phase  lesions appear rapidly, perhaps in a few weeks & are aggressive,
destructive looking with poorly defined margins, sclerotic (-)

Regress to a well defined osteolytic lesion (a punched out lesion) with reactive sclerotic, cortical
erosion, periosteal reaction (single or laminated ‘onion peel’ appearance), soft tissue involvement,
sometimes pathological fracture occurs 9

The healing phase by spontaneous regression  peripheral sclerosis round the lesion & reconstitution of
the bony structure  as one lesion resolves another may appear in a different part of the skeleton 8
 PLAIN RADIOGRAPH (cont…) 1

CALVARIA

- Diameter size  1 to 15 cm
- The parietal bones >>>
- In patients with systemic
disease, lesions are generally
larger & can measure up to 25
cm
The bevelled edges - A button
are due to greater sequestrum (lucent
involvement of the defect with central
inner than the outer calcification &
table (asymmetrical) surrounding
sclerosis)
 PLAIN X – RAY(cont…)1,13
• The typical radiographic
appearance of EG in the extremities
 a punched-out lytic-bone lesion
without reactive sclerosis.

Permeative
lesion
• Thick linear periosteal reaction

• In the first 6 - 12 months after Geographic

diagnosis  additional lesions may lesion,
occur or there may be progression lamelated
of existing lesions periosteal
reaction

Patel A. Eosinophilic Granuloma. https://www.orthobullets.com/pathology/8041/eosinophilic-granuloma

 PLAIN RADIOGRAPH (cont…) 13

Lesions in the long bones are

 Most often in the
diaphysis >> epiphysis &
metaphysis

Fig. EG in humerus.

Fig. EG of femur Fig. EG 4-year-old with bilateral involvement.

 PLAIN RADIOGRAPH (cont…) 8

Apparent bone expansion may result from thickening of the overlying periosteum, especially if the cortex
has been partially eroded or infarction has occurred

Fig. Here the clavicle, is often associated with layered periosteal Fig. A purely osteolytic lesion is present in the mandible, with
new bone causing bony expansion. Ill-defined areas of resorption sharply / well-defined, slightly scalloped margins. The lamina dura
may be visualised in the lesion. has been destroyed. The teeth seem to 'float in air‘ or floating
tooth.
 PLAIN RADIOGRAPH (cont…) 8
• In the spine  variable, ranging from isolated lytic lesions to a more
significant vertebral collapse partially or completely, that involves the
pedicles & posterior vertebral elements (vertebra plana), peridural spread &
paraspinal soft tissue components

• The most commonly affected  thoracic spine

• The disc spaces on other side remain intact & may appear widened

• EG is the most common cause of vertebra plana

• As healing occurs, remarkably good reconstitution of these vertebral bodies Fig. Vertebral lesions in the thoracic
may take place if sufficient years of growth remain. spine. The bodies of T7 & T8 have
collapsed
 USG 9,16
Valid tools to detect the extent & composition of osseous defects

In most cases, a hypervascularized soft-tissue mass surrounds the affected bone

Fig. From the right forehead Fig. Using a linear broad-band transducer, working at 5–12 MHz, revealing a hypoechoic
showing a hypoechoic mass with loss mass (white arrows) at the left ninth rib
of the normal bone contour
(curved arrow). Part of the cerebral
cortex is seen (white arrow) through
the osteolytic mass
 CT SCAN 9,13,17
Useful for  evaluating osseous EG lesions, confirming periosteal reaction, determining the extent of cortical
destruction, soft tissue involvement

In the skull, usually the outer & inner table are destroyed

CT-guided biopsy is also useful for diagnosing, with low morbidity & a diagnostic accuracy of 70 - 100 %

Fig. CT scan of the forearm revealed destruction of the

cortex of the proximal metaphyseo-diaphyseal region of the
radius with an associated periosteal reaction 9
Fig. EG skull CT note the bevelled edges
 MRI 9,10,13,18
Help in revealing multiple lesions

Although MRI is very sensitive, the findings remain non-specific  highly variable & may mimic
primary bone tumors or bone infections

Due to extensive marrow involvement & soft tissue abnormalities on MRI  lesions may
frequently be confused with malignant bone tumors

Bone marrow involvement  characterized by diffuse signal change in the medullary bone &
surrounding soft tissues

Soft tissue involvement  characterized by a diffuse extra-osseous edema

MRI is presently the most informative & powerful modality in the staging, treatment and follow-
up of bone LCH
Fig. In the red circle, the lesion is highlighted. On MRI  the lesion appears
isointense (in T1) & slightly hypointense (in T2) without dural Involvement 19

Fig. MRI of the complete spine

of the boy with a vertebra plana
at the level of the third thoracic
vertebra (T3) 2
 TREATMENT 1,3,8,10
Controversial with different therapeutic approaches claiming effectiveness

Non-Operative

• Observation alone : a self-limited process & it is reasonable to treat with observation alone
• Bracing : to prevent progressive kyphosis of the spine
• Low dose irradiation (600 - 800 cGy) : for lesions in the spine that compromise stability, lesions not
amenable to injection or open treatment (incision / perform internal fixation)
• Chemotherapy : for lesions in weight-bearing bones with a large soft tissue component, diffuse lesions
• Corticosteroid injection : isolated lesions, can be performed after curettage as well, healing response
within 2 months after injection

Operative

• Curettage & bone grafting : for lesions that endanger the articular surface or are a risk for impending
fractures
• Spinal deformity correction : progressive spine deformity refractory to bracing
 Fig.
a. Lateral radiograph of the lumbar spine of a 6-year-old girl with a painful osteolytic
lesion of the VL 2 with vertebral plana deformity. CT-guided frozen section biopsy
showed EG; intralesional methylprednisolone injection was performed.
b Lateral radiograph of the lumbar spine shows complete reconstitution of the lesion 7
years after diagnosis & treatment 12
 PROGNOSIS 1,4,9,12

Variable  depends on the patient’s age of diagnosis & the number of foci

Better  Age > 2 years, absence of pulmonary, hepatic, haemopoietic lesions or multiple bony involvement

The unifocal variety is generally considered relatively indolent  sometime spontaneous healing / cured after local
excision or irradiation.

Surgery may result in a higher rate of recurrence than less aggressive procedures (biopsy)

Biopsy may effect on bone healing & EG lesions reconstitution  the time required for resolution is unpredictable, can
be associated with significant morbidity secondary to unremitting pain, restricted activity, growth disturbance, or
pathological fracture

So, if unifocal EG not treated properly  mortality can reach up to 50%, especially when affecting cerebral bones due
to direct intracranial extension with the development of encephalitis or venous thrombosis

The potential for unifocal lesion  become multifocal should not be underestimate  long term follow-up is mandatory.
The multifocal variety is a serious form of disease, but does not lead to malignant transformation. If it expands
elsewhere but bones then  called Hand-Schuller-Christian disease
 DD EG OSTEOMYELITIS METASTASIS OF MM HAEMANGIOMA
BONE
LESION ON CALVARIA

Punched out,varied, Osteopeni regional, Inhomogen, varied, may Punched out lesion, With sclerotic margin,
well-defined, beveled involucrum, button be mix with blastic lesion uniform (< 1 cm) sunburst like
edge, button sequestrum
sequestrum, sclerotic(-)
LESION ON VERTEBRA

Plana vertebra, thoracal Endosteal scalloping, Compression fracture, Endosteal V. thoracal >>>, collapsed
>>>, post. Element >>, lumbal >>>, involve DIV mix type destruct,post.elmnt<<, vertebra on aggressive
not involve DIV osteopenia difus type, post.elmnt <<
PREDILECTION Calvaria >> vertebra >> Long bone >> vertebra Any bone (not specific) Vertebra >> calvaria Vertebra, calvaria
ribs >> long bone
PERIOSTEAL REACTION (+) (+) (+) (-) (-)
31
GENDER & PEAK AGE M, < 20 ys M / F, Any age M / F, > 30 ys M, > 40 ys F, 4-5 decade
 RESUME OF EG  a rare, benign tumor-like disorder, characterized by clonal
proliferation of antigen-presenting mononuclear cells of dendritic
origin known as Langerhans cells
 a variant of Langerhan’s cell histiocytosis (LCH) or
histiocytosis X group of disease  the mildest expression, the
 Non Operative : observation, bracing, low most cases
dose irradiation, chemotherapy,
corticosteroid injection
 Operative : curettage and bone grafting,  Most commonly in children (80% of afflicted < 20
spinal deformity correction years of age).
M : F  2 : 1

 OM
 Any bone may be affected
 Metastasis
(skull,spine,ribs,clavicle,mandibula,pel
 MM
vis,long bones)
 Haemangioma

 Plain Radiograph, USG, CT,

MRI
 Lytic lesion, sclerotic rim (-),  Unclear
solitary >>, diaphysis >>, axial  Theories : immune disorders,
skeleton >> neoplastic process, virus,
 Beveled edge, button bacteria, genetic
sequestrum

 Clinical Path. : non specific, moderate rise ESR, mild

 Asymptomatic & Symptomatic  variable, non-specific
LABORATORY leukocytosis CLINICAL (pain, localized swelling, mild fever, sometimes a
FINDING  Anatomical Path. : Biopsy (Langerhans cell, FINDING pathological fracture, localized or diffuse back pain,
abundant eosinophils, inflammatory cells)
increasingly kyphotic posture, radiculopathy
 Electron microscope : Birbeck granules
 QUIZ
A 6 years old boy with his parents, admitted to the hospital, due to pain over his head, back, and left thigh for the past
several months. No history of trauma. On examination, he was febrile, with marked local swelling over the proximal
third of the femur. There was no enlargement of regional lymph nodes. Initial blood tests showed mild leukocytosis,
normal C-reactive protein, moderate rise ESR. The child had not taken any treatment except occasional analgesics.
He went some x ray examination, and the result :

The most probable diagnosis for this boy is :

a. Osteosarcoma
b. Osteomyelitis
c. Multiple Myeloma
d. Eosinophilic granuloma
e. Tuberculosis
 REFERENCES
1. Agarwal A, et al. A Case of Unifocal Eosinophilic Granuloma of the Mandible in an Adult Female: A Case Report.2012 : 1-4.
doi:10.1155/2012/521726
2. Kocak T, et al. Eosinophilic granuloma of the spine involving C1 and pulmonary infiltration in young children – Presentation of two cases with a
follow-up over 10 years including review of the literature. Journal of Orthopaedics 15 (2018) 808–811. https://doi.org/10.1016/j.jor.2018.08.012
3. Patel A. Eosinophilic Granuloma. https://www.orthobullets.com/pathology/8041/eosinophilic-granuloma
4. Bodner , et al. Eosinophilic granuloma of the bone: Ultrasonographic imaging. Australasian Radiology. (2002). 46 , 418–421
5. http://youtu.be/UOjnhOJ4x4E. Langerhans-Cell Histiocytosis of the bone (“The great mimicker”).
6. Garg S, et al. Langerhans cell histiocytosis of the spine in children: Long-term follow-up. Journal of Bone and Joint Surgery. 2004. 86,8. 1740-
1750.
7. Khatami, et al. Radiologic Manifestations Of Langerhans Cell Histiocytosis In Pediatrics. PJR 2010; 20(3): 114-120
8. Sutton D. Textbook of radiology and imaging. Vol. 2. 2003. London : Elsevier Science Limited
9. Chada M, et al. Solitary eosinophilic granuloma of the radius An unusual differential diagnosis. Acta Orthop. Belg., 2007, 73, 413-417.
10. Erol, et al. Long-term follow-up of long and flat bone eosinophilic granulomas managed only with biopsy. Acta Orthop Traumatol Turc
2015;49(2):144-150. doi: 10.3944/AOTT.2015.14.0116
11. Sherwani RK, et al. Eosinophilic granuloma of the mandible: diagnostic dilemma. BMJ Case Rep 2014. doi:10.1136/bcr-2013-200274 1
12. Angelini A, et al. Current concepts for the diagnosis and management of eosinophilic granuloma of bone. J Orthop Traumatol (2017) 18:83–90.
DOI 10.1007/s10195-016-0434-7
13. Karlala S. Imaging of langerhans histiocytosis - Pictorial essay. J Med Sci Res. 2017; 5(1):33-39. DOI: http://dx.doi.
org/10.17727/JMSR.2017/5-7
14. Devi Y, et al. Langerhans cell histiocytosis with oral manifestations: a rare and unusual case report. J Clin Exp Dent. 2012;4(4):e252-5
15. Grana N. Langerhans Cell Histiocytosis.Cancer Control, 2014 : 21 (4).
16. Bodner G, et al. Eosinophilic granuloma of the bone: Ultrasonographic imaging. Australasian Radiology. (2002). 46 : , 418–421
17. Kasukawa Y, et al. Eosinophilic Granuloma Arising from the Sacrum: A Case Report. Open Journal of Orthopedics, 2011, 1, 5-8
doi:10.4236/ojo.2011.12002
18. Hashmi. Langerhans cell histiocytosis of long bones: MR imaging and complete follow up study. Journal of Cancer Research and Therapeutics
- April-June 2012 - Volume 8 - Issue 2
19. Imperator. Eosinophilic granuloma of the skull vault: A case report.. Curr Pediatr Res 2016; 20 (1&2): 210-212
TERIMA KASIH
&
MOHON ASUPAN
 Renonce HT, Mangunsudirdjo S,
Soeripto, Bras J. Cranial unifocal
langerhans cell histiocytosis in a female
child: a difficult case with S-100 and
CD1a immunonegativity.
J Med SSccii, 2011 (43) : 2 : 150-160
Grana N. Langerhans Cell Histiocytosis.Cancer Control, 2014 : 21 (4)
Renonce HT, Mangunsudirdjo S, Soeripto, Bras J. Cranial unifocal langerhans cell histiocytosis in a female child: a difficult case with S-100 and CD1a immunonegativity.
J Med SSccii, 2011 (43) : 2 : 150-160
Renonce HT, Mangunsudirdjo S, Soeripto, Bras J. Cranial unifocal langerhans cell histiocytosis in a female child: a difficult case with S-100 and CD1a immunonegativity.
J Med SSccii, 2011 (43) : 2 : 150-160
Karlala S. Imaging of langerhans histiocytosis - Pictorial essay. J Med Sci Res. 2017; 5(1):33-39. DOI: http://dx.doi. org/10.17727/JMSR.2017/5-7
Garg S, et al. Langerhans cell histiocytosis of the spine in children: Long-term follow-up.
Journal of Bone and Joint Surgery. 2004. 86,8. 1740-1750.
Garg S, et al. Langerhans cell histiocytosis of the spine in children: Long-term follow-up.
Journal of Bone and Joint Surgery. 2004. 86,8. 1740-1750.

Unifocal
Eosinophilic Granuloma
(EG)
 The mildest form (Sutton,
Agarwal)
 Slowly progressing disease
 Localized benign
 Can be monoostotic or
polyostotic disease
 Commonly affects the skeletal
system (skeletal manifestations
LCH)
 Rare skin lesion (<10%)
 No extraskeletal involvement
 Usually 5–15 years old
 Chronic
Langerhan’s Cell Histiocytosis
(LCH) 2,5,6,7
Multifocal Unisystem
Hand-Schüller-Christian
disease (HSC)
 Presents with the clinical triad
(scull lesion, exophthalmos &
diabetes insipidus)
 Multifocal bone lesions &
extraskeletal involvement of the
reticuloendothelial system (RES),
pituitary gland
 Skin & oral lesions (30%)
 Usually seen in children 1–5
years old
 Subacute to chronic
WHO
Multifocal Multisystem
Letterer-Siwe disease
(LSD)
 The most malignant form: Disseminated
clusters of Langerhans cells are found
throughout the body (acute disseminated
multisystem form)
 Rapidly progressing disease
 Disseminated involvement of the RES with a
fulminant
 Mucocutaneus lesions, including gingiva &
oral mucosa, seborrheic dermatitis, purpuric
red brown nodules (90-100%)
 Clinical feature : fever, weight loss,
lymphadenopathy, hepatosplenomegaly,
pancytopenia, bone lesions
 Lung, liver, spleen involvement
 Usually in children < 2 years old
 Acute
DIFFERENTIATI multiple lytic collapse of a a solitary lesion
ON lesions of bones single vertebral
of calvaria. body
 Langerhan’s  Ewing’s  Osteomyelitis
histiocytosis tumour,  Ewing's
 Tuberculosis  Metastasis tumour (has a
 Osteomyelitis from a similar age
 Hyperparathyr neuroblastom incidence
odism a, (SUTTON)
 Leukemia/lym  Benign
phoma osteoblastoma
 Cystic or an atypical
angiomatosis tuberculous
 Fibrous focus.
dysplasia  Tuberculosis
 Myeloma is becoming
 Metastasis commoner in
the ‘Western’
world again.

KARALA
 EG EWING SARCOMA OM GCT FIBROUS DYSPLASIA NOF ABC SBC

Lesion Ground glass / haze - Fluid level

appearance of the (CT)
matrix
- Narrow zone
transition
Acute phase

Long bones + +

Age < 20 ys 3-4 decade < 20 ys child

Etiology Genetic
translocation of t
(11,22)
Histologic feature Small round blue
cells
Cortical erosion + +
Bone marrow edema
Soft tissue component + - - -

Periosteal reaction + -

Button sequestrum + +
Brodie abcess
(microbial
investigation)
Location Diaphysi - Metaphysis & epipysis of long - Metaphysis - eccemtric - centrally
s of long bone of long bone
bone - eccentrically
- Extend to subchondral bone
 EOSINOPHIL
Haematopoetic
Stem Cell (HSC)

 A variety of white blood cells, one of the immune system components

 They are granulocytes that develop during hematopoiesis in the bone
marrow before migrating into blood, after which they are terminally
differentiated & do not multiply
 Eosinophil result in tissue
 Normally, they are found in the medulla, thymus, lymph nodes, spleen,
lower GIT, ovaries, uterus BUT NOT in the lungs, skin, esophagus, or
some internal organs
 Function :
- Combating multicellular infection
- Associated with allergy
- As APC (antigen presenting cell)
- Can causing inflammation & tissue damage
- Regulate other immune cell function eg.CD 4 T cell, dendritic cell, B cell,
mast cell, neutrophil, basophil
 Eosinophilia = the presence of > 500 eosinophills/ml of blood, typically
seen in people with a parasitic infestation of intestine, autoimmune,
collagen vascular disease (eg. Rheumatoid arthritis)

http://en.m.Wikipedia.org/wiki/Eosinophil