UNUSUAL CASE OF EOSINOPHILIC ASCITES AND PERIPHERAL EOSINOPHILIA

Abstract

Introduction Drug reactions and atopic disease are common etiologies of peripheral eosinophilia in the United States, while helminthic infections, malignancy and hypereosinophilic syndrome (HES) are rare. Here we describe a patient with an unusual etiology for peripheral eosinophilia. Case Description 24-year old previously healthy female presented with acute abdominal pain, distension and diarrhea. She had traveled to Brazil and Italy in the previous three years. Initial peripheral absolute eosinophil count (AEC) was 4.67 k/uL. Abdominal ultrasound showed moderate ascites. Paracentesis yielded 2.3L of ascites fluid; analysis showed 3165 WBC with 92% eosinophils. Stool culture grew few Blastocystis hominis. Pathology showed 12 esophageal and >100 colonic eosinophils/hpf without significant abnormality in the stomach or duodenum. Bone marrow biopsy did not show evidence of malignancy. Allergy skin testing demonstrated sensitization to several aeroallergens. HES workup was normal. Gastroenterology considered treatment for eosinophilic gastroenteritis versus parasite infection. She was treated with metronidazole for Blastocystis, and symptoms improved over the following 8 weeks. Peripheral AEC decreased to 0.48 k/uL by 12 weeks post-treatment, without return of symptoms. Discussion Blastocystis hominis is a protozoan parasite rarely implicated in human disease or peripheral eosinophilia. It can be found in stool of healthy individuals, though gastrointestinal symptoms may require treatment. Eosinophilic ascites has been associated with eosinophilic gastroenteritis, which may self-resolve or require corticosteroid treatment. Steroid treatment during parasitic infection, however, can lead to disseminated disease. In this case, where etiology of the eosinophilia was unclear, it was important to treat a possible parasitic infection prior to considering corticosteroid treatment. Drug reactions and atopic disease are common etiologies of peripheral eosinophilia in the United States, while helminthic infections, malignancy and hypereosinophilic syndrome (HES) are rare. Here we describe a patient with an unusual etiology for peripheral eosinophilia. 24-year old previously healthy female presented with acute abdominal pain, distension and diarrhea. She had traveled to Brazil and Italy in the previous three years. Initial peripheral absolute eosinophil count (AEC) was 4.67 k/uL. Abdominal ultrasound showed moderate ascites. Paracentesis yielded 2.3L of ascites fluid; analysis showed 3165 WBC with 92% eosinophils. Stool culture grew few Blastocystis hominis. Pathology showed 12 esophageal and >100 colonic eosinophils/hpf without significant abnormality in the stomach or duodenum. Bone marrow biopsy did not show evidence of malignancy. Allergy skin testing demonstrated sensitization to several aeroallergens. HES workup was normal. Gastroenterology considered treatment for eosinophilic gastroenteritis versus parasite infection. She was treated with metronidazole for Blastocystis, and symptoms improved over the following 8 weeks. Peripheral AEC decreased to 0.48 k/uL by 12 weeks post-treatment, without return of symptoms. Blastocystis hominis is a protozoan parasite rarely implicated in human disease or peripheral eosinophilia. It can be found in stool of healthy individuals, though gastrointestinal symptoms may require treatment. Eosinophilic ascites has been associated with eosinophilic gastroenteritis, which may self-resolve or require corticosteroid treatment. Steroid treatment during parasitic infection, however, can lead to disseminated disease. In this case, where etiology of the eosinophilia was unclear, it was important to treat a possible parasitic infection prior to considering corticosteroid treatment.