Case Presentation:
A 59-year-old male with a remote history of traumatic left hemidiaphragmatic injury presented to the hospital with acute onset substernal chest pain, nausea, diarrhea, and diaphoresis while eating a hamburger. He reported a six month history of early satiety, prandial discomfort, and bloating with a 20 kg weight loss. Three weeks prior to admission, he was diagnosed with suspected intermittent gastric volvulus on an Upper GI series. Abdominal CT scan in the Emergency Department demonstrated persistent elevation of the left hemidiaphragm, with upward migration of the stomach, spleen, and colon without evidence of obstruction. Laboratory testing was notable for 21% eosinophils (Absolute Eosinophil Count (AEC) of 1800 cells/microL), which had also been present five months earlier. His acute symptoms improved several hours after presentation though he continued to have prandial discomfort with minimal oral intake. On Hospital Day 2 the eosinophil count rose to 39% (AEC of 2600 cells/microL). Strongyloides serology, stool ova and parasites, AM cortisol, HIV, and peripheral smear were unremarkable. An IgE level was elevated. An upper endoscopy was performed and demonstrated patchy mucosal nodularity in the lower esophageal sphincter, and an erosive gastropathy with shallow linear ulcerations in the proximal body. Pathology revealed eosinophilic infiltration in the lamina propria and muscularis mucosae of the stomach, duodenum, and distal esophagus consistent with eosinophilic gastroenteritis.
Discussion:
Eosinophilic gastroenteritis is a rare inflammatory condition characterized by the triad of eosinophilic infiltration of segments of the gastrointestinal tract, abnormalities of gastrointestinal function, and exclusion of other diseases that cause peripheral eosinophilia. The most common symptoms are abdominal pain, nausea, vomiting, early satiety, and diarrhea, all of which were present in this patient. Patients may also present with features of malabsorption, failure to thrive, anemia, gastric outlet or small intestinal obstruction, and ascites. Peripheral eosinophilia is present in 80% of patients with counts ranging from 5% to 35% with an average AEC of 1100 cells/microL. IgE levels are usually elevated. Other etiologies of peripheral eosinophilia such as medications, parasitic infections (i.e., Strongyloides), adrenal dysfunction, myeloproliferative neoplasm, and HIV should be evaluated and in this patient were ruled out. Diagnosis is based on the presence of eosinophilic infiltration of the gastrointestinal tract on biopsy. Treatment with prednisone is usually effective.
Conclusions: Eosinophilic gastroenteritis should be considered in patients with a combination of chronic nonspecific GI symptoms and eosinophilia. Given the rarity of this condition, approximately 80% of patients have symptoms for several years before it is clinically recognized. Once other causes of eosinophilia have been excluded, an endoscopy should be pursued to establish the diagnosis.