Diarrhea, Ascites, and Eosinophilia

Abstract

A 41 yr-old male was admitted with crampy periumbilical and right lower quadrant abdominal pain of 1 month duration. He had associated diarrhea with 4-9 soft to watery bowel movements per day. Twenty-four to 36 hours prior to admission, he experienced nausea and vomiting. He denied fever, rash, joint pain, oral ulcers, eye symptoms or dysphagia. He unintentionally lost 15-lbs over the past 2 weeks. He denied recent travel or antibiotic use. Past medical history included GERD and hyperlipidemia. Current medications included omeprazole and atorvastatin. On physical exam, he was hemodynamically stable with no fever. He had right lower quadrant and periumbilical tenderness. Blood work showed WBC 11.4, 23.7% eosinophils (Nl < 7%), absolute eosinophil count 2.7K/cmm (Nl < 0.7) with similar intermittent elevations over the past 9 years, 58% neutrophils, hemoglobin 16.2 and a normal complete metabolic panel. Stool studies were negative for infectious etiology. CT abdomen and pelvis revealed distal small bowel wall thickening with mucosal enhancement and reticulation of the adjacent fat (Figure 1). There was a small amount of ascites. Colonoscopy revealed a normal colon but a prominent ileocecal valve and edematous terminal ileum with 3 erosions (Figure 2). EGD showed rings and furrows in the esophagus suspicious for eosinophilic esophagitis.Figure 1Figure 2Biopsies showed marked increase of lamina propria eosinophils in the terminal ileum (Figure 3) and ileocecal valve as well as increased intraepithelial eosinophils in the esophagus >65 hpf. Random colonic biopsies showed patchy increase in eosinophils but gastric and duodenal biopsies were normal. Further work up to exclude food allergy, malignancy, HIV, infectious enteritis, celiac disease, vasculitis, C1 esterase deficiency, and other autoimmune diseases were unrevealing. Bone marrow biopsy was not consistent with a myeloproliferative process but showed increased eosinophils.Figure 3The patient was diagnosed with hypereosinophilic syndrome with end organ damage manifesting in the GI tract. The patient was treated with budesonide with resolution of diarrhea and pain within days. Peripheral eosinophils decreased after 2 weeks (WBC 9.1, 0.7K/cmm absolute eosinophils; 7.6%). This case highlights that eosinophilia can predate end organ damage by years. The most common GI involvement is that of stomach and duodenum, but rarely, as in our case, these sites are spared, so other GI sites should be randomly biopsied so the diagnosis is not missed.