Crystal Clear: A Unique Clue to Diagnosis in a Patient With Recurrent Nausea and Vomiting

Abstract

Question: A 36-year-old African-American woman with a history of hypertension, asthma, and ongoing tobacco use presented to our hospital with abdominal pain, nausea, vomiting, and intermittent diarrhea. She had recently been treated for a breast abscess with trimethoprim/ sulfamethoxazole and subsequently admitted to another hospital for acute pancreatitis with lipase of 1314 U/L. Her symptoms improved on discharge; however, she continued to have diarrhea. On admission to our hospital 3 days later, her physical examination was only notable for moderate abdominal tenderness to palpation in the epigastric region without peritoneal signs, and her lipase was elevated at 582 U/L. She was also noted to have a peripheral eosinophilia of 11.3% (total white blood cell count, 7.96 K/mm; absolute eosinophil count, 900 K/mm), initially attributed to recent sulfa exposure, which had been hypothesized to cause her pancreatitis given normal hepatobiliary imaging and no history of alcohol intake. The patient’s nausea and vomiting improved with limited oral intake. She did, however, experience intermittent loose bowel movements. Stool studies for ova and parasites were sent. A trichrome stain of stool is shown in Figure A. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.