Scleroderma-like fasciitis without eosinophilia after L-tryptophan ingestion

A 53-year-old man developed severe sclerodermatous skin changes and a neuromyopathic process, consistent with the eosinophilia-myalgia syndrome, 2 months after discontinuation of L-Tryptophan (L-Try). His peripheral eosinophil count was within normal limits upon presentation and remained so throughout the illness. Currently the Centers for Disease Control surveillance definition requires peripheral eosinophilia greater than 1000 cells/mm3. Eosinophilia-myalgia syndrome may need to be part of a differential diagnosis even in the absence of peripheral eosinophilia.