Background: Enteral eosinophilia may manifest from an infectious trigger or a primary inflammatory process. Parasitic infections may mimic eosinophilic gastroenteritis clinically and pathologically with eosinophilic infiltration of the gut wall. Management sharply differs depending on etiology. We present a case of a patient with risk factors for both infectious and reactive eosinophilic gastroenteritis.
Methods: A 35 year old male with a history of Burkitt’s lymphoma in remission presents with two days of diffuse muscle cramping in the setting of subacute diarrhea. His diarrhea developed since his return from Haiti approximately four months prior to admission. His initial white blood cell count was within normal range, yet it revealed a marked 18% eosinophilia. The patient was admitted for dehydration and electrolyte abnormalities including hypokalemia, hypomagnesemia, hypophosphatemia and hypocalcaemia.
Results: The diffuse muscle cramping improved after intravenous hydration and electrolytes supplementation. Workup for his chronic diarrhea included an extensive negative infectious stool analysis as well as a negative allergen analysis. CT abdomen and pelvis revealed diffuse lymphadenopathy in the abdomen, retroperitoneum, and axilla. A biopsy of the axillary lymph node was negative for recurrence of lymphoma and showed only a reactive hyperplasia. Endoscopy showed gastritis in the stomach. Colonoscopy revealed congestion and edematous erosions in the colon and terminal ileum. Pathology reported diffuse eosinophilic gastroenteritis. He was given one day of empiric treatment with albendazole for parasitic infection prior to consideration of empiric steroids. He reported rapid improvement in his diarrhea after the anti-parasitic treatment and was discharged home with an outpatient follow up visit to strongly consider a trial of steroid treatment.
Conclusions: Eosinophilic gastroenteritis is an inflammatory disorder characterized by eosinophilic infiltration of the gastrointestinal tract without a known cause of eosinophilia. Common symptoms include abdominal pain, nausea, vomiting, and diarrhea. Parasitic infection of the gastrointestinal tract may present with similar symptoms and be clinically indistinguishable. This case illustrates the importance of appropriate management of eosinophilia despite a clear etiology. Even after an extensive workup, infection cannot always be excluded. Hospitalists faced with this dilemma should err on the side of delaying steroids to avoid possible infectious exacerbation.