Eosinophilic ascites, an unusual presentation of eosinophilic gastroenteritis: A case report and review

Successful Introduction of Benralizumab for Eosinophilic Ascites

Eosinophilic ascites is a rare disorder, reported in both adult and pediatric patients, characterized by high eosinophil counts in the peritoneal fluid. Eosinophilic ascites appears as a manifestation of various diseases such as parasitic and fungal infections, malignancy, and hypereosinophilic syndrome. It also represents an uncommon manifestation of eosinophilic gastroenteritis, usually treated with corticosteroids. We present the case of a 16-year-old woman with abdominal distention related to abundant ascites. Further work-up concluded that it was eosinophilic gastroenteritis complicated with eosinophilic ascites. The patient was on oral steroids for three weeks, but various abdominal relapses were observed, leading to the introduction of benralizumab, as a steroid-sparing therapy with a favorable outcome.

Postpartum Eosinophilic Ascites: A Case Report

Eosinophilic gastrointestinal diseases (EGID) are a group of conditions characterized by histopathologic eosinophilic infiltrates in one or more segments of the gastrointestinal (GI) tract. It occurs in the absence of known causes for eosinophilia. It can affect every part of the gastrointestinal tract, but eosinophilic ascites (EA) is uncommon. There is a clinical overlap between EGID and GI involvement of hypereosinophilic syndrome (HES), so distinguishing them may not be easy. We report a case of eosinophilic gastroenteritis in a 26-year-old-woman with the uncommon presentation of eosinophilic ascites after delivery. It is vital to maintain a high grade of suspicion to diagnose these disorders and exclude the secondary causes since treatment varies. In addition, the occurrence of this postpartum syndrome has been described, so it is essential to recognize this entity in this period.

An Unusual Case of Eosinophilic Ascites with Pleural Effusion - A Rare Manifestation of Eosinophilic Gastroenteritis (EGE)

Eosinophilic gastroenteritis (EGE) is a rare disease characterized by tissue eosinophilia and can affect any part of gastrointestinal (GI) tract from the esophagus to the rectum, although stomach and small intestine are sites most frequently involved. We hereby describe an unusual case of eosinophilic gastroenteritis affecting the stomach, small intestine, colon and rectum involving the mucosa and serosa. A twenty-oneyearold student presented with fever, diarrhea, ascites and right pleural effusion. Total leucocyte count was high with marked eosinophilia. Ascitic and pleural fluid were exudates with low adenosine deaminase (ADA) level and predominant eosinophils. Biopsy specimens of the stomach, duodenum, ileum, colon and rectum showed dense eosinophilic infiltration of lamina propria. Based on the constellation of clinical features and investigations, a diagnosis of EGE was made, and therapy with prednisone was started. Symptoms and peripheral eosinophilia rapidly resolved. It is thus imperative to diagnose this disease early and institute the necessary treatment.

Eosinophilic ascites as an uncommon presentation of eosinophilic gastroenteritis: A case report

BACKGROUND

Eosinophilic gastroenteritis (EGE) is defined by the presence of gastrointestinal symptoms, with an abnormal eosinophilic infiltrate of the intestine wall and exclusion of other causes of secondary eosinophilia. EGE has three clinical presentations, depending on the depth of eosinophilic infiltration of the bowel wall. It individualizes into three types, namely mucosal, muscular, and subserosal. Eosinophilic ascites, which is caused by edema and eosinophilic inflammation of the serosal layer of the small bowel wall, is the most uncommon presentation of EGE.

CASE SUMMARY

A 30-year-old Egyptian woman presented with pain in the epigastrium and diffuse abdominal distension. Past medical history comprised allergy to iron injections (for iron deficiency anemia). Clinical examination showed moderate abdominal distention (palpation) and shifting dullness (percussion) suggestive of moderate ascites; mild right pleural effusion was also suspected, but findings were otherwise unremarkable. Abdominal and pelvic examinations by ultrasound and contrast-enhanced computed tomography showed moderate ascites, mild right pleural effusion, and diffuse thickening of the antrum and small bowel loops. Endoscopy of the upper gastrointestinal tract revealed mild diffuse hyperemia of the esophagus, stomach and duodenum, with no relevant findings in the histopathology of biopsy specimens taken from these sites. Laboratory results showed eosinophilia in the peripheral blood and marked increase of eosinophils in the ascitic fluid. Treatment with corticosteroids resulted in normalization of the laboratory test results, and the ascites resolved within a week of initiation of therapy.

CONCLUSION

Eosinophilic ascites, characterized by increased eosinophils in peripheral blood and ascitic fluid, showed dramatic response to steroid therapy.

Vitamin D deficiency causing eosinophilic esophagogastroenteritis and ascites: a rare association

A 54-year-old Chinese man presented with ascites for 2 weeks. He had a preceding 2-year history of intermittent dysphagia, lethargy and general malaise. Blood investigations revealed leucocytosis with eosinophilia of 26.5%, whereas paracentesis showed turbid fluid with high protein content (45 g/L) and a high white blood cell count of 5580/µL, predominantly eosinophils (90%). An incidental assay of vitamin D showed a very low level of 13.5 ng/mL. No other cause of ascites was found. Gastroscopy was normal except for duodenitis. However, biopsies from lower oesophagus confirmed the presence of eosinophilic infiltration. Following vitamin D replacement, the patient experienced marked improvement in symptoms of dysphagia within 2 weeks and no recurrence of ascites after 3 months. The reason for the patient's vitamin D deficiency remains unclear. The marked improvement in the patient's health indicates a causative role of vitamin D deficiency in causing eosinophilic esophagogastroenteritis and associated eosinophilic ascites.

A Challenging Case of Recurrent Eosinophilic Peritonitis

Eosinophilic peritonitis is a rare presentation of eosinophilic gastroenteritis and is characterized by eosinophil-rich inflammation in any part of the gastrointestinal tract in the absence of secondary causes of eosinophilia. We report a case of a 48-year-old female who had recurrent hospital admissions due to abdominal pain and distension secondary to relapsing eosinophilic peritonitis.

Eosinophilic gastroenteritis in pregnancy: A review of the literature

Eosinophilic gastroenteritis (EGE) is an uncommon and heterogeneous disease characterized by eosinophilic infiltration of the gastrointestinal tract. There are very few reports in literature describing pregnancies in EGE patients, and no review has ever been published. We found a total of 12 cases including one that occurred in our clinic. In 5 out of 12 cases, EGE was diagnosed after delivery and pregnancies are described as uneventful. Of the 5 patients who already had a diagnosis of EGE before pregnancy, only one registered an improvement of symptoms during gestation, while the rest had no significant changes, and their pregnancies needed to be monitored as high risk. Regarding pregnancy complications, only two patients had a pre-term delivery. Both patients had not only EGE, but a remarkable obstetrical history, that could slightly complicate the interpretation of the events that occurred in their pregnancies. More studies are necessary to demonstrate if EGE is connected with pre-term onset of labor. It's not easy to define the reasons of some patient's pre term labor, and we could suppose that a combination of different mechanisms leads to this condition of breakdown of maternal-fetal tolerance. Nevertheless, we know that spontaneous preterm labor is a syndrome attributable to multiple pathologic processes and most of them are yet to be understood. However, we cannot exclude that EGE is related to late preterm delivery. We hope that this review will provide some measures of guidance to those clinicians who must satisfy the questions of young female patients diagnosed with EGE and wishing for a pregnancy.

Causes of eosinophilic ascites – A systematic review

Background . In the last years an uprising interest for a relatively unknown entity, eosinophilic ascites (EA), has been recorded.

Our aim is to investigate the potential causes of EA development, as well as clinical, laboratory, endoscopic and radiologic features, management and outcome in these patients.

Methods . The following research was performed on PubMed (MEDLINE) database using the medical subject headings [Mesh] terms “Ascites” AND “Eosinophils”.

Results . A total of 284 results, dating from 1962 onwards, were found and abstracts were examined. 131 papers were excluded and the remaining 153 publications, consisting in case reports and series of cases, were analyzed.

From 171 patients with EA, 127 subjects (74%) had EGE, 17 (10%) parasitic and fungal infections, 11(7%) Hypereosinophilic syndrome and 16 patients (9%) less common diseases (eosinophilic pancreatitis, chronic eosinophilic leukemia, myelofibrosis, T-cell lymphoma, Churg Strauss Syndrome, Systemic lupus erythematosus, Familial paroxysmal polyserositis and Ménétrier’s disease). High eosinophil blood count and IgE levels as well as gastrointestinal symptoms are frequent. The diagnosis is based on ascitic fluid analysis, imaging and endoscopic biopsies. Therapy with corticosteroids results in resolution of eosinophilic ascites in almost all patients.

Conclusion . In most cases, in the absence of allergy, parasitic infections, malignancy, hematological disorders, peritoneal tuberculosis, inflammatory bowel disease or autoimmune disease, EA develops as a manifestation of eosinophilic gastroenteritis.

A 22-year-old male patient with ascites

A 22-year-old male patient presented with a 3-day history of abdominal pain, diarrhoea, nausea and vomiting. He reported abdominal distention of a couple of weeks' duration. He had been hospitalised 7 months earlier, owing to the same symptoms, however, the cause was never clarified. Initial examination showed abdominal distention and blood tests indicated eosinophilia. An abdominal CT scan showed mild ascites and a diffuse thickening of the small intestinal loops, and a cystic formation 3 cm in diameter on the liver. The differential diagnosis included parasite infection and eosinophilic gastroenteritis. Liver MRI revealed a simple biliary cyst. Microbiological tests, stool and blood cultures as well as stool examination for parasites were negative. The diagnostic paracentesis revealed eosinophilic ascites. An endoscopy was performed and histopathology revealed presence of moderate to marked lymphoplasmacytic infiltrate containing eosinophils, compatible with eosinophilic gastroenteritis. The patient responded well to the initiation of corticosteroids.

Acute eosinophilic ascites: An unusual form of an unusual case

Eosinophilic gastroenteritis (EGE) is an uncommon disease characterised by eosinophilic infiltration in the gastrointestinal tract. EGE may involve more than one layer of the gastrointestinal tract. Clinical features depend on the layer and location which is involved. We report an unusual case of eosinophilic ascites associated with antinuclear antibody positivity, which is an unusual variety of serosal form of EGE.

Eosinophilic ascites, as a rare presentation of eosinophilic gastroenteritis

BACKGROUND

Eosinophilic ascites is the most unusual presentation of eosinophilic gastroenteritis (EGE), caused by edema and eosinophilic inflammation of the small bowel wall's serosal layer.

CASE REPORT

We report the case of a 37-year-old woman, who presented with diffuse abdominal pain, nausea, abdominal distension, moderate ascites and diarrhea of two weeks duration. The rest of physical and clinical examination was unremarkable, and her past medical history was uneventful. Magnetic Resonance Imaging showed the presence of ascites and diffuse thickening of small bowel wall, but did not detect a primary malignancy in the abdominal cavity; and no signs of portal hypertension or liver damage. Laboratory test results revealed essential peripheral blood eosinophilia, elevated serum IgE and marked increase of eosinophils in the abdominal fluid. Treatment with corticosteroids normalized laboratory tests results, and the ascites resolved immediately.

CONCLUSIONS

EGE is a rare entity and it should be kept in mind in patients of unexplained ascites. The absence of primary malignancy on imaging, coupled with marked increase of fluid esinophilia and immediate response to treatment with steroids, confirm indirectly the diagnosis of EGE. Hippokratia 2014; 18 (3): 275-277.

Eosinophilic ascites with marked peripheral eosinophilia: a diagnostic challenge

Eosinophilic disease of the gastrointestinal tract is rare and is characterized by the presence of gastrointestinal symptoms in association with eosinophilic infiltration of any part of the gastrointestinal tract. Clinical presentation of eosinophilic gastroenteritis (EGE) varies not only by the part of the gastrointestinal tract involved but also with the depth of eosinophilic infiltration of the gut wall. We describe the case of a 41-year-old woman with a history of atopy who presented with severe abdominal pain and diarrhoea. Investigations showed large-volume eosinophil-rich ascites and a markedly elevated peripheral blood eosinophil count and immunoglobulin E level. Bone marrow aspirate, trephine biopsy and T-cell studies showed no evidence of underlying haematological malignancy. Vasculitic disease and parasitic infection were systematically excluded. Colonic and upper gastrointestinal biopsies confirmed a diagnosis of EGE with eosinophilic ascites. The patient was treated with systemic corticosteroids and dietary allergen elimination with dramatic therapeutic response. The diagnostic and therapeutic challenges associated with EGE in its various forms are discussed.

Clinical and morphological features of serosal form of eosinophilic gastroenteritis in a retrospective study of 10 children

BACKGROUND

Eosinophilic gastroenteritis (EG) is an increasingly recognized inflammatory disease characterized by gastrointestinal (GI) symptoms and eosinophilic infiltration of the GI tract. Serosal form is one subtype of EG. The aetiology and pathogenesis of EG are unknown and the diagnosis and treatment properly are difficult for physician.

METHODS

A retrospective study of 10 paediatric patients (mean age 10.8 years) was performed to review records of medical, endoscopic, ultrasonographic findings and histological features.

RESULTS

All the cases presented abdominal pain symptom in this study. Supra-umbilical pain was the main location of pain. The pain intensity of cases was from mild to moderate. Vomiting and diarrhoea may also be found. All the cases manifested as peripheral eosinophilia and eosinophilic ascites (EA) detected by ultrasonograph and ascetic fluid white cell differential count were analysed. Erythema was the predominate feature seen on endoscopy. Histologic examination showed patchy eosinophilic infiltration in the GI tract in all patients. Symptom remission within 1 week and ascites absorbed within 2-3 weeks in all the patients treated with steroids.

CONCLUSION

Serosal form of EG affects paediatric patients as well as adults, which can be diagnosed early and correctly through realising the character of the disease. Histopathology is the gold standard for diagnosis. Corticosteroids are the first line therapy.

Diagnosis and treatment of eosinophilic gastroenteritis: An analysis of 67 cases

AIM: To investigate the clinical characteristics, diagnosis, and therapy of eosinophilic gastroenteritis (EG) to improve the awareness of this disease.

METHODS: Clinical data for 67 patents with EG treated in our department were retrospectively analyzed, including history, clinical manifestations, laboratory examinations, endoscopic findings, treatment, and reasons for misdiagnosis.

RESULTS: Most EG patients had nonspecific gastrointestinal symptoms. The number of eosinophils in peripheral blood and bone marrow increased significantly. Endoscopic features of EG did not show specificity. Infiltration by a large number of eosinophils could be detected by biopsies. Glucocorticoid treatment was effective. Forty-six (46/67, 68.7%) patients were not initially diagnosed with EG, and the causes of misdiagnosis were diverse.

CONCLUSION: Clinical and endoscopic presentations of EG are complex and diverse, but not specific, which may lead to misdiagnosis. The presence of eosinophilia in peripheral blood and ascites, especially the increase in the number of eosinophils in the gastrointestinal mucosa, supports the diagnosis. Glucocorticoid treatment can lead to perfect results.

Eosinophilic gastroenteritis: an update

Eosinophilic gastroenteritis (EGE) is characterized by dense eosinophilic inflammation of one or several digestive tract sections. The symptoms include abdominal pain, weight loss, vomiting and diarrhea. Biopsy samples taken during endoscopic examination allows the diagnosis of the disease. An infiltration of >30 eosinophils per high-power field in at least five high-power fields, exhibiting signs of eosinophilic degranulation and extending to the muscularis mucosa or submucosa are all histological indications of EGE. EGE is traditionally classified into three forms depending on the depth of inflammation in the wall (mucosal, muscular or serosal). This, together with the digestive tract segments involved, determines the clinical presentation. The natural history of EGE includes three different evolutionary patterns, since patients may suffer a single outbreak, a recurrent course or even chronic disease. Corticosteroids are the most frequently used therapy for EGE; dietary treatments should be also considered. Surgery has been limited to solving obstruction and small bowel perforation.

Eosinophilic gastroenteritis with bloody ascites: a case report

Eosinophilic gastroentertis (EG) is a very rare disease of unknown cause, characterized by peripheral eosinophilia and focal or difuse eosinophilic infiltration of the gastrointestinal tract. Here we report a case of eosinophilic gastroenteritis with bloody ascites in a 15-year-old male patient who presented to our hospital with nausea, vomiting, debilitation, and intermittent diarrhea for 10 d. Laboratory data showed that his WBC count was 18.28×10⁹/L and his eosinophil percentage was 57.61%. He developed bloody ascitic fluid, in which the protein level was 46 g/L, WBC count was 7040×10⁶/L, and eosinophil percentage was 68%. The Rivalta test was positive. Ultrasound and CT demonstrated bowel wall thickness in the right colon and ascites. Gastroendoscopy showed severe multifocal erythematous esophagitis, gastritis and duodenitis, and a ring-like discoloration with mucosal particle hyperplasia in the lower esophagus. Colonoscopy revealed severe inflammation in the lower ileum, the opening of vermiform appendix, and right colon, with erosions, thickening, exudates, mucosal particle hyperplasia, and stricture formation. Microscopic examination of the biopsied specimens showed eosinophilic infiltration. After treatment with prednisone, his clinical manifestations regressed.

Eosinophilic gastroenteritis: a case series from iran

BACKGROUND Eosinophilic gastroenteritis (EG) is a rare inflammatory disorder of the gastrointestinal (GI) tract. There have been several case series of patients with EG from the western world and East Asia. However, there has not been a report of patients with EG from the Middle East region. The aim of this study is to describe clinical characteristics and treatment response in a series of EG patients from Iran. METHODS We retrospectively reviewed charts with a diagnosis of EG from 1997 to 2010 at Shariati Hospital and the private clinics of the authors. Clinical characteristics of the patients were evaluated, and the treatment response and relapse rate were assessed. RESULTS Twenty-two patients (9 male) with EG were identified. Mean age of the patients was 45.1±15.5 (range: 27-75) years. Median duration between symptom onset and diagnosis was 12 (range 1- 48) months. Twenty (90%) patients had mucosal involvement, one (5%) had muscular involvement and one (5%) had subserosal involvement. Patients were followed for a median duration of 36.5 (range 4-123) months. Two patients had spontaneous remission with supportive care. The remaining 20 patients responded well to oral corticosteroid treatments. The relapse rate was 33%. Episodes of relapse were successfully controlled with a repeat course of corticosteroids. Two patients with several relapses required maintenance treatment with azathioprine. CONCLUSION The clinical characteristics and treatment responses of EG patients from Iran are similar to reports from other parts of the world. Patients need to undergo close follow up after treatment to detect early signs of relapse.