S2833 A Midlife Crisis - A Rare Case of Late Onset Eosinophilic Gastroenteritis in a Middle-Aged Male, Caused by a New Onset Dairy Allergy

Abstract

INTRODUCTION: Eosinophilic gastroenteritis (EG) is a rare disease of the digestive tract characterized by gastrointestinal tract (GIT) eosinophilia, abnormal function of the GIT and exclusion of other causes of eosinophilia (Eos). It is seen in 28/100,000 persons with equal male to female distribution with the majority of cases seen in children. Majority of occurrences can be linked to a food hypersensitivity especially if atopy (asthma, eczema, hay fever) is co-expressed. CASE DESCRIPTION/METHODS: 54-year-old male with dyspepsia and atopy presented with abdominal pain, vomiting, diarrhea and weight loss. He was discharged with diagnosis of gastroenteritis and dyspepsia. On last admission CBC showed Eos 39% and CT scan with gastric, small bowel and colonic thickening. Stool enteric pathogens, C. diff, ova and parasites, ESR/CRP, autoimmune panel, IGE levels, EGD and colonoscopy with biopsies were obtained. Autoimmune serologies were negative, ESR and CRP were elevated. Duodenal biopsy was negative for celiac disease but gastric and colonic biopsies revealed 34 Eos per Hpf. Patient worked on a dairy farm and consumed 4 servings of dairy per day his entire life. During the hospitalization he was placed on a dairy-free diet and was started on oral steroids. His symptoms improved in 48 hours. As an outpatient he underwent allergen testing, revealing grass allergies as well as a severe dairy allergy. He was tapered off steroids, placed on a PPI and with diet modification has been asymptomatic for over a year. DISCUSSION: EG in adults is likely missed as it can be self limited in up to 50% of cases. Careful history, high level of suspicion and a meticulous diagnostic approach is imperative to decrease the need for hospitalizations, and improve quality of life in patients with EG. Overall, there is conflicting data in regards to long term management. Studies of antihistamines, mast-cell stabilizers, leukotriene receptor antagonists, even biologic monoclonal antibodies as an adjunct to dietary modification all have yielded equivocal results. Corticosteroids are considered as the gold standard of therapy, but their unfavorable long term effects limit their use. Over the last 16 years there has been an increase in prevalence of EG, and there is growing evidence linking functional dyspepsia (FD) with an increase in GIT Eos. Prevalence of food sensitivities in FD has not been adequately studied, however it can possibly identify a largely underdiagnosed population with EG.Figure 1.: CT with IV Contrast showing small bowel and gastric wall thickening, with mesenteric edema and small volume ascites.Figure 2.: Endoscopic view of the Gastric Body and Antrum (Upper Panels), and small bowel with mild erythema (Lower Panels).Figure 3.: Hematoxylin and Eosin stain of representative gastric mucosa with noted eosinophilic infiltrate (white arrow).