VA Boston Healthcare System Jamaica Plain, MA, United States
Horst C. Weber, MD1, Judith Strymish, MD2, Qin Huang, MD, PhD2 1VA Boston Healthcare System, Jamaica Plain, MA; 2VA Boston Healthcare System, West Roxbury, MA
Introduction: Chronic diarrhea is a common clinical presentation in GI practice and numerous causes need to be considered during the evaluation including infectious, inflammatory, and metabolic or functional bowel disorders.
Case Description/Methods: A 58-year old white, obese male patient was admitted because of 2-year history of recurrent episodes of non-bloody, watery diarrhea with up to 12 daily bowel movements associated with crampy abdominal pain. He noted nausea and vomiting with a 30-pound weight loss but denied dysphagia, odynophagia, and GERD symptoms. There was no sick contact and no travel. His past medical history was significant for diarrhea-predominant irritable bowel syndrome (IBS), chronic pancreatitis, and seasonal allergies. He lived alone with several dogs, cats, and rabbits. Two years ago, EGD and colonoscopy showed unspecific duodenitis and gastritis, and 2 colonic adenomas were removed. Persistent peripheral eosinophilia of 15-25% ( > 1,500 Eosinophils/mm3) was noted for the previous 2 years. The physical examination was unremarkable. Tests for helminths, parasites, and myeloid neoplasms remained negative. Colonoscopy was performed and showed normal mucosa. Congested duodenal mucosa and mild gastric erythema were noted during EGD (Fig. 1). Dense eosinophilic infiltrates along the entire length of the digestive tract were noted without evidence of pathological organisms, celiac disease, and microscopic colitis (Fig. 2). Abundant mast cells were identified in corresponding segments of the GI tract (Fig.3). Tryptase levels were normal, IgE was > 10,000 IU/ml (nl 0-100), and skin testing was positive to cat standard, ragweed, and rye, but negative for food allergies. RAST showed positive results with dog and cat dander and dairy. The patient was advised to exclude dairy products from his diet. In follow up, his symptoms improved, and eosinophilia was no longer detectable.
Discussion: Episodic chronic watery diarrhea represented a diagnostic challenge in this case because of underlying IBS-D and chronic pancreatitis. Furthermore, the persistent moderate eosinophilia and the highly unusual intense eosinophilic inflammation of the entire intestinal mucosa resulted in comprehensive testing to exclude helminthic and parasitic infections and hematologic malignancies. Resolution of symptoms and peripheral eosinophilia upon exclusion of dairy suggested that concurrent eosinophilic esophagitis, gastroenteritis, and colitis were due to an allergic reaction to dairy.
Figure: Representative endoscopic images of the gastrointestinal tract as indicated are shown in row A. Images in row B depict corresponding representative photomicrographs (hematoxylin-eosin stain) of histopathologic changes with unusually dense eosinophilic infiltrate in the lamina propria, epithelium, and muscularis. Where submucosa is present, eosinophils also are noted without evidence of pathologic organisms. No morphologic evidence for celiac disease or microscopic colitis is identified. The bottom panel (row C) shows corresponding representative photomicrographs of CD117-immunoreactive (brown-stained) mast cells in mucosal biopsies of the esophagus, stomach, duodenum, and colon.
Disclosures: Horst Weber indicated no relevant financial relationships. Judith Strymish indicated no relevant financial relationships. Qin Huang indicated no relevant financial relationships.
Horst C. Weber, MD1, Judith Strymish, MD2, Qin Huang, MD, PhD2. P2308 - Eosinophilic Colitis Accompanied by Synchronous Eosinophilic Esophagitis and Gastroenteritis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.