Is eosinophilic gastroenteritis a primary disease or a secondary developing entity due to parasitosis?

To the Editor: Eosinophilic gastroenteritis (EGE) is a rare condition characterized by eosinophilic infiltration of the gastrointestinal tract. (1,2)

We report a patient with eosinophilic gastroenteritis, who was admitted to the hospital because of abdominal pain and distension, and was diagnosed as having Strongyloides stercoralis infestation after investigation.

A 27-year-old-female patient was admitted to our hospital because of abdominal pain and distention. Three years earlier, she had been diagnosed as having bilateral pleural effusions. Pleural fluid analysis was consistent with exudate, and adenosine deaminase level of fluid was normal. Nonspecific pleuritis was diagnosed by pleural biopsy. There were no acid-fast bacilli and culture was also negative. Massive ascites, increased pleural effusion and moderate pericardial effusion were found during procedures. Ascitic fluid showed leukocyte 200/[micro]L (eosinophils 60%) and serum ascitic fluid albumin gradient was < 11 g/L, not consistent with portal hypertension. The patient had normal physical findings except for massive ascites and bilateral pleural effusions. Peritoneal biopsy showed pathologic granulation tissue. Bone marrow aspiration showed relatively increased megakaryocytes, eosinophils and normocellular bone marrow findings. Upper and lower gastrointestinal endoscopic findings were normal and eosinophilic infiltration was seen on duodenal biopsy. All other investigations for parasites, bacterial infections, malignancies and collagen tissue diseases were normal. A diagnostic laparatomy was done and biopsies showed a pathologically eosinophilic infiltration. Due to the development of dyspnea, an echocardiography was done that revealed massive pericardial effusion. Nematode larvae were found on pleural biopsy samples which were taken during a partial pericardioectomy operation, Ivermectin was started prophylactically for presumed Strongyloides stercoralis. Although the patient was compliant with the medication, she continued to have abdominal distention and was referred to our hospital for investigation 10 months later.

Her physical examination showed cachexia, tese ascites, and costodiaphragmatic sinuses which were bilaterally closed. Laboratory findings included an erythrocyte sedimentation rate of 36 mm/h, hemoglobin 11.3 mg/dL, hematocrit 33%, leukocytes 4,500/[micro]L (neutrophils 45%, lymphocytes 41%, eosinophils 7%) and thrombocytes of 268 000/[micro]L. She had hypoalbuminemia (2.5 gr/L) and hypergammaglobulinemia. Chest x-ray revealed bilaterally closed costophrenic sinuses. A diagnosis of eosinophilia (32%) and nonportal hypertension ascites was made. Histopathologic examination of fluid showed that histiocytic giant cells and proliferated mesothelial cells were present. Stool cultures for helminths, larvae and protozoons x 3 were normal. Immunoelectrophoresis showed no pathologic findings. Biopsies were taken during an upper gastrointestinal endoscopic examination which showed remarkably increased eosinophils. Abdominal ultrasonography confirmed the presence of ascites and echocardiography showed pericardial effusion. According to these findings, the patient was diagnosed with eosinophilic gastroenteritis and was started on methylprednisolone 1 mg/kg orally. Her abdominal pain and ascites disappeared promptly. One month following treatment initiation, paracentesis revealed 3% eosinophils.

As a result, eosinophilic gastroenteritis of unknown etiology was diagnosed, with presumed allergic predisposed disease, characterized by relapse and remission. (3) Diagnosis of eosinophilic gastroenteritis may be made if eosinophilic infiltration is found clearly on tissues and no other reason is evident. The diagnosis of eosinophilic gastroenteritis is supported due to the presence of eosinophils in the paracentesis fluid, as well as on the biopsy samples and decreased ascites on follow up. In addition, the patient responded to corticosteroid therapy clinically and by laboratory findings.

In conclusion, according to the above findings, is eosinophilic gastroenteritis a primary disease or a secondarily developing entity due to parasitosis?

Gonenc Kocabay, MD

Emine Gul, MD

Department of Internal Medicine

Istanbul Faculty of Medicine

Istanbul University

Istanbul, Turkey

Atahan Cagatay, MD

Halit Ozsut, MD

Haluk Eraksoy, MD

Semra Calangu, MD

Department of Infectious Diseases and Clinical Microbiology

Istanbul Faculty of Medicine

Istanbul University Istanbul, Tukey

Yakut Akyon Yilmaz, MD

Department of Microbiology and Clinical Microbiology

Hacettepe Faculty of Medicine

Hacettepe University

Ankara, Turkey

References

1. Chen MJ, Chu CH, Lin SC, et al. Eosinophilic gastroenteritis: clinical experience with 15 patients. World J Gastroenterol 2003;9:2813-2816.

2. MyNgoc TN, Szpakowski JL. Eosinophilic gastroenteritis. Available at: http://www.emedicine.com.

3. Barabino AV, Castellano E, Gandullia P, et al. Chronic eosinophilic ascites in a very young child. Eur J Pediatr 2003;162:666-668.