Case Presentation: A 44-year-old man with a history of asthma presented to the emergency department with six weeks of non-bloody diarrhea and one week of abdominal distension. He described no clear trigger for these symptoms and denied associated fever, chills, melena, and dysphagia. He noted a similar episode three years prior, which self-resolved after three months. Physical exam demonstrated marked abdominal distension with a positive fluid wave. There was no abdominal tenderness, rigidity, or guarding. Laboratory work-up revealed a white blood cell count of 14.1 and an elevated absolute eosinophil count (AEC) of 7.34. The patient’s complete metabolic panel, lipase, and lactic acid were within normal limits. A CT scan of the abdomen demonstrated widespread gastrointestinal wall thickening, moderate ascites, and a questionable jejunal lesion. The patient was admitted to the floor for further work-up.During his admission, the patient received infectious disease (ID) studies, a paracentesis, a CT enterography, and an upper endoscopy. His ID studies, including an HIV screen, a GI panel, and a stool ova/parasite panel, were negative. Paracentesis removed 4.2 liters, and ascitic labs were notable for a white count of 9,129 with 92% eosinophils. CT enterography showed focal jejunal wall thickening, and cytogenetics were negative for malignancy. Esophageal biopsies demonstrated intraepithelial eosinophils up to 15/ high power field (HPF) (Figure 1). Given high clinical suspicion for eosinophilic esophagitis (EoE), the patient was started on a six-food elimination diet (6 FED) and a prednisone taper. At his two-week follow up visit, he reported symptom improvement and his AEC had improved to 0.23.
Discussion: EoE is a TH2-mediated disease characterized by eosinophilic infiltration of the esophageal mucosa (1). While EoE is a rare immunologic disorder, its prevalence has steadily increased over the last three decades, likely due to a combination of increased awareness and a rise in environmental allergic exposures (2). The most common presenting symptoms of EoE include dysphagia, food impaction, heartburn, and abdominal pain; extra-intestinal presentations are rare (3). While multifactorial, diagnosis typically requires an esophageal biopsy demonstrating >15 eosinophils/HPF (4). However, there are acknowledged limitations to biopsy, including sampling error and inability to sample the muscularis mucosa.We describe a case of EoE which notably presented with eosinophilic ascites, an unusual presentation of the disease which highlights the importance of keeping a high index of suspicion for EoE even with non-typical presentations. Additionally, we describe a case in which, despite not strictly meeting the diagnostic threshold of > 15 eosinophils/HPF on biopsy, empiric treatment led to improvement in symptoms and AEC. This may underscore the role of empiric EoE treatment in cases with significant pre-test probability, may point to a need for improved diagnostic techniques/criteria for the disease.
Conclusions: Eosinophilic esophagitis is a rare but increasingly acknowledged cause of dysphagia, heartburn, and abdominal pain. We demonstrate an unusual case of EoE presenting with ascites, demonstrating the importance of maintaining a high index of suspicion given variable disease presentation. Additionally, this case suggests that empiric treatment of EoE may be warranted when clinical suspicion is high, even in the presence of non-diagnostic esophageal biopsies.
