Diffuse Eosinophilic Gastrointestinal Disease: 2011

We describe a 26-year-old female with one year of intermittent abdominal pain and vomiting, found to have diffuse eosinophilic infiltrate of her gastrointestinal tract unresponsive to steroids. A 26-year-old female with a history of multiple food and seasonal allergies presented with one year of nausea, vomiting, diarrhea, abdominal pain, and weight loss. Labs were significant for anemia and peripheral eosinophilia of 10.5%. Remaining labs, including inflammatory markers and stool studies, were normal. Endoscopy revealed esophageal exudates and multiple non-bleeding gastric ulcers with biopsies showing intraepithelial eosinophils over 100 eos/hpf. Colonoscopy revealed non-specific focal ileitis and random colon biopsies showed focal areas of 50-60 eos/hpf. Video capsule endoscopy only showed nonspecific findings. Treatment with intravenous and oral steroids was not tolerated due to increased pain. Cromolyn, montelukast, antihistamines and enteral steroids were tried with minimal improvement. The patient was started on total parenteral nutrition as additional therapy is evaluated. Eosinophilic gastrointestinal disorders (EGIDs) are remarkably rare. Estimated prevalences of eosinophilic esophagitis, gastritis, gastroenteritis, and colitis are 55, 6.3, 8.4 and 3.3/100,000, respectively.1,2 Our patient is unique in that she has eosinophilic esophagitis, gastritis, enteritis, and colitis. Common EGID symptoms include abdominal pain, nausea, vomiting, weight loss, and diarrhea.3 Additionally, coexisting allergic conditions are seen with approximately 38.5-45.6% of eosinophilic gastritis, gastroenteritis, and colitis patients.2 There are no specific treatment guidelines for EGIDs. Prednisone is considered the mainstay treatment with most studies showing 90% remission.3 Our patient, however, did not respond to leukotriene receptor antagonists, mast cell stabilizers, systemic or enteral steroid treatments. Based on few case reports, remaining options include immunosuppression, interleukin-5 antagonists or anti-IgE. EGID subtypes are rare with several treatment options available. Our case is unique in its diffuse gastrointestinal involvement and lack of response to traditional therapy. With a paucity of data and no proven strategies for treatment, our cases poses an unusual therapeutic challenge.Figure: Antral Ulcer (Low Power Field).Figure: Esophagus (High Power Field).