Various Clinical Presentations of Eosinophilic Enteritis

Abstract

Purpose: Eosinophilic enteritis is part of a broad spectrum of eosinophilic inflammatory diseases characterized by the infiltration of eosinophils to different degrees anywhere from the esophagus to the rectum. Eosinophilic esophagitis is currently the most well recognized and characterized eosinophilic disorder of the gastrointestinal tract. However, eosinophilic enteritis remains an uncommon disease with a paucity of published data. We will present three cases of eosinophilic enteritis with various clinical presentations and courses. The first case is a 47 year old gentleman presenting with right upper quadrant abdominal pain, emesis, and watery diarrhea of 4 days duration. His past medical history was significant for seizure disorder that was controlled with medications and a history of alcoholism. Laboratory studies were significant for peripheral eosinophilia. Extensive infectious work-up was negative; however, Charcot Leyden crystals were seen on stool. EGD revealed mild esophagitis, gastritis, and duodenitis. Biopsies of the duodenum were consistent with eosinophilic enteritis. Random biopsies of the normal appearing colon and terminal ileum also revealed more than 25 eosinophils per high power field. The patient was treated with a course of prednisone while as inpatient, with transition to budesonide as outpatient with resolution. The second case is a 30 year old gentleman with chronic intermittent periumbilical abdominal pain and diarrhea which had worsened over the week prior to presentation. He noted 5 bowel movements daily with occasional bright red blood in the stool with a 15 lb weight loss over the last year. CT scan revealed significant thickening of the distal ileum as well as stranding in the pelvic mesentery. Endoscopy was significant for gastric ulceration and stenosis of the terminal ileum. The patient eventually underwent laparoscopic ileocecectomy for presumed partial small bowel obstruction suspected to be secondary to fibrostenotic Crohn's disease. Review of the surgical specimens showed increased eosinophils with no signs of chronicity or architectural evidence of Crohn's disease. And finally, 26 year old female presented with 4 week history of bilateral lower extremity edema with recent extension to her waist and periorbital area. She denied abdominal pain, diarrhea, change in her bowel habits or GI blood loss. She denies a history of liver, kidney, or cardiac problems. Initial labs revealed a peripheral eosinophilia of 22% and an albumin of 1.5 without proteinuria. EGD was notable for ulcerative duodenitis. Biopsies revealed a significant portion of eosinophils. She underwent allergy testing with elimination diet resulting in the resolution of her symptoms.