[Sclerosing mucoepidermoid carcinoma with eosinophilia of thyroid gland]

Sclerosing mucoepidermoid carcinoma with stromal eosinophilia of thyroid gland is represented less than 100 cases in the world literature. We present a rare case of sclerosing mucoepidermoid carcinona with stromal eosinophilia in a 69-year-old woman who has been observed for multinodular goiter for more than 3 years. Cytological examination revealed a picture most of all corresponding to a malignant neoplasm (Bethesda V). The patient underwent a thyroidectomy. Pathomorphological examination revealed a neoplasm of mixed structure with foci of cribriform structures and squamous metaplasia with areas of keratinization. According to the IHC study, the expression of TTF-1, p63, cytokeratins 5/6 were positive, while there were no expression of thyroglobulin with its positive reaction in the thyroid tissue. Additional histochemical staining with Alcian blue revealed a positive reaction with a homogeneous acellular substance of the tumor. A comprehensive morphological study with the use of additional stains made it possible to accurately establish the diagnosis, which will determine the further tactics of managing the patient.

Severe Eosinophilic Myocarditis in the Portion of Left Ventricular Wall Excised to Insert a Left Ventricular Assist Device for Severe Heart Failure

Described herein are 3 adults in whom histologic study of the left ventricular myocardium excised ("LV core") to insert a left ventricular assist device (LVAD) disclosed severe acute myocarditis and the inflammatory cells included numerous eosinophils (eosinophilic myocarditis). Examination of the clinical records disclosed elevated absolute eosinophil counts at the time of insertion of the LVAD and the counts rapidly (<30 days) returned to normal after the operation. Because of the numerous medications that each patient was taking at the time of LVAD insertion, identification of a specific initiating medication as its cause was not possible. Of the 3 patients, 2 had idiopathic-dilated cardiomyopathy and 1 had ischemic cardiomyopathy and each had had heart failure for years. The eosinophilic myocarditis in these 3 patients appears to have been transient and superimposed on the earlier cardiomyopathy.

EOSINOPHILIC ANGIOCENTRIC FIBROSIS AS A CAUSE OF NASAL OBSTRUCTION. A CASE REPORT

Eosinophilic angiocentric fibrosis (EAF) is a rare benign lesion of unknown aetiology, found predominantly in the upper respiratory tract. The fibrosis must be confirmed by considering other lesions in the differential diagnosis. The typical histological characteristics are the basis for establishing the diagnosis. We present a patient with long-term nasal obstruction caused by EAF. The patient had repeated resections of the lesion for its recurrences. As follows from the literature, radical resection is crucial for the treatment of EAF. This procedure may be difficult at times given the extent and localization of the disease..

Chronic rhinosinusitis in eosinophilic granulomatosis with polyangiitis: clinical presentation and antineutrophil cytoplasmic antibodies

BACKGROUND

In this study we aim to describe presenting characteristics and identify prognostic factors for disease resolution in patients with chronic rhinosinusitis (CRS) in the setting of eosinophilic granulomatosis with polyangiitis (EGPA).

METHODS

Patients evaluated at a tertiary care center with diagnoses of EGPA and CRS were identified. Descriptive statistics were obtained. Univariate analysis was used to search for prognostic factors associated with higher Lund-Mackay score at presentation and disease resolution.

RESULTS

Forty-four patients were included with a mean age of 52.7 (standard deviation, 14) years. Twenty-one patients (47.7%) were female, all had a diagnosis of asthma, and 36 (83.7%) had eosinophils >10%. Common presenting symptoms for CRS included nasal discharge (87.9%) followed by nasal congestion (83.9%) and facial pain and pressure (83.8%). Medical management of CRS included systemic corticosteroids (93.2%) and systemic antibiotics (75%). Surgical intervention occurred in 29 patients (67%). Nine patients (20.5%) had resolution of sinus symptoms, including 4 with imaging confirmation. Fourteen patients (31.8%) had continued CRS, but with improved symptoms, whereas 9 patients (20.5%) had continued CRS with no improvement in symptoms. Eleven patients (25%) were lost to follow-up and 4 (9.1%) died. Univariate analysis did not show antineutrophil cytoplasmic antibody positivity, presence of peripheral eosinophilia, gender, age, or absence of systemic therapy to be predictive of higher Lund-Mackay score at presentation or predictive of disease resolution.

CONCLUSION

CRS in patients with EGPA is often refractory to medical and surgical management. Treatment of these patients should occur in a multidisciplinary setting.

The relationship of eosinophilia with outcomes of Hirschsprung disease in children

PURPOSE

It has been postulated that children with Hirschsprung disease (HD) and mucosal eosinophilia have been thought to have poorer outcome, but supporting evidence is lacking. The objective of our study was to review the outcomes of children with HD and mucosal eosinophilia.

METHODS

A single center, retrospective review was conducted on all patients diagnosed with HD between 1999 and 2016. Pathology specimens were evaluated for mucosal eosinophilia. Demographics, complications, and outcomes were analyzed.

RESULTS

A total of 100 patients were diagnosed with HD and 27 had mucosal eosinophilia. Median age at the time of surgery was 12 days (8, 30) and 82 were males. Comparing patients with HD with and without mucosal eosinophilia, there was no statistically significant difference in time to bowel function (2 days vs. 2 days; p = 0.85), time to start feeds (3 days vs. 3 days; p = 0.78) and time to goal feeds (5 days vs. 5 days; p = 0.47). There was no statistically significant difference in feeding issues (13% vs. 9%; p = 1.0) and stooling issues (60% vs. 50%; p = 0.38). There was no statistically significant difference in postoperative complications and readmissions rates (63% vs. 56%; p = 0.53).

CONCLUSION

Hirschsprung-associated mucosal eosinophilia may not increase postoperative complications, and may not change feeding and bowel management. Further prospective studies are in process to evaluate long term follow-up outcomes for this patient population.

Pyloric obstruction due to massive eosinophilic infiltration in a young adult dog

A 16-month-old dog was presented with chronic vomiting, anorexia, progressive weight loss, and melena. Exploratory laparotomy revealed a massive pyloric eosinophilic infiltration leading to pyloric obstruction that was treated successfully with pylorectomy. This is a novel clinical presentation of eosinophilic gastritis and highlights the need to consider it as a differential diagnosis for pyloric obstruction.

[A Case of Eosinophilic Enteritis Needed to Distinguish from a Tumor of the Small Intestine]

A 75-year-old woman was diagnosed with aplastic anemia 6 months ago and was under follow-up at our hospital. She had originallypresented to our hospital because of ongoing diarrhea and abdominal pain. Her blood tests showed a rise in inflammatorymarkers (WBC count was 6,900/mL[eosinophil was 1.3%]and CRP was 8.60mg/dL). Her abdominal computed tomography(CT)scan showed gastric wall and small intestine edema as well as ascites. There was no evidence of free air. We diagnosed her with generalized peritonitis and performed an emergencyoperation . Intra-operatively, moderate amounts of yellowish ascitic fluid were noted, as was a diffuse reddening of the small intestine. We performed a partial resection of the small intestine. Histopathological examination showed transmural infiltration of inflammatorycells mainly comprising eosinophilic leukocytes. Eosinophils were also present in the ascitic fluid. Post-operative blood tests confirmed eosinophilic, and we diagnosed her with eosinophilic enteritis. She was started on corticosteroids and her symptoms improved immediately. We report a rare case of eosinophilic enteritis with a review of the pertinent literature.

Post-operative steroid treatment for eosinophilic-type sinonasal polyposis

CONCLUSIONS

The preliminary finding of significantly lower eosinophilic-type CRSwNP recurrence rates in patients with associated asthma or ASA intolerance treated post-operatively with local nasal and oral steroids warrants further investigation in larger, prospective series.

OBJECTIVE

A high recurrence rate after functional endoscopic sinus surgery (FESS) has been widely reported in patients with eosinophilic-type chronic rhinosinusitis with nasal polyps (CRSwNP). This study compared the influence of two post-operative medical treatments - local nasal steroids alone vs local nasal and oral steroids - on the recurrence of eosinophilic-type CRSwNP.

METHOD

Between January 2009-December 2010, 32 patients with eosinophilic-type CRSwNP received local steroid nasal therapy after FESS (Group A); from January 2011 onwards, another 28 patients were treated post-operatively with the same nasal treatment plus two cycles a year of oral steroids (Group B). All patients in both groups had a follow-up of at least 36 months.

RESULTS

Groups A and B did not differ significantly in recurrence rate (31.25% vs 32.14%, p = 1) or disease-free interval (p = 0.91), but Group B patients who were asthmatic or ASA-intolerant had a significantly lower recurrence rate than Group A patients with asthma or ASA intolerance (p = 0.04 and p = 0.004, respectively).

Sclerosing mucoepidermoid carcinoma with eosinophilia of thyroid gland in a male patient: a case report and literature review

Sclerosing mucoepidermoid carcinoma with eosinophilia (SMECE) was first described by Chan et al in 1991. It is characterized by nest or strands of epidermoid tumor cells with squamous differentiation, rare mucous cells, prominent sclerotic stroma, eosinophilic and lymphoplasmacytic infiltration, and a background of chronic lymphocytic thyroiditis in the non-neoplastic thyroid gland. It is important to recognize SMECE of thyroid and differentiate it from squamous cell carcinoma or other neoplasms with squamous differentiation/metaplasia. In published cases, the SMECE of thyroid gland predominantly occurs in women. We report a case of SMECE of thyroid in a 45-year-old male patient. All cases in male patients were Caucasian described in English literature, and our case is the first one in Asian.

Idiopathic focal eosinophilic enteritis (IFEE), an emerging cause of abdominal pain in horses: the effect of age, time and geographical location on risk

Background

Idiopathic focal eosinophilic enteritis (IFEE) is an emerging cause of abdominal pain (colic) in horses that frequently requires surgical intervention to prevent death. The epidemiology of IFEE is poorly understood and it is difficult to diagnose pre-operatively. The aetiology of this condition and methods of possible prevention are currently unknown. The aims of this study were to investigate temporal and spatial heterogeneity in IFEE risk and to ascertain the effect of horse age on risk.

Methodology/Principal Findings

A retrospective, nested case-control study was undertaken using data from 85 IFEE cases and 848 randomly selected controls admitted to a UK equine hospital for exploratory laparotomy to investigate the cause of colic over a 10-year period. Generalised additive models (GAMs) were used to quantify temporal and age effects on the odds of IFEE and to provide mapped estimates of ‘residual’ risk over the study region. The relative risk of IFEE increased over the study period (p = 0.001) and a seasonal pattern was evident (p<0.01) with greatest risk of IFEE being identified between the months of July and November. IFEE risk decreased with increasing age (p<0.001) with younger (0–5 years old) horses being at greatest risk. The mapped surface estimate exhibited significantly atypical sub-regions (p<0.001) with increased IFEE risk in horses residing in the North-West of the study region.

Conclusions/Significance

IFEE was found to exhibit both spatial and temporal variation in risk and is more likely to occur in younger horses. This information may help to identify horses at increased risk of IFEE, provide clues about the aetiology of this condition and to identify areas that require further research.

Eosinophilic colitis mimicking caecal malignancy

Primary eosinophilic diseases of the gastrointestinal tract are increasingly being recognised in adults. Bosinophilic colitis is even less understood and presents with highly variable symptoms depending on the depth of mucosal involvement. We are presenting a case of primary eosinophilic colitis presenting with diarrhoea and localized caecal perforation. Pre-operative computed tomography suggested caecal malignancy and possible livier mnetastasis. Patient underwent an emergency laparoscopic right hemicoloectomy and histology revealed eosinophilic colitis. Post- operative period was complicated by pulmonary embolism and deep vein thrombosis. Secondary causes of eosinophilia were appropriately investigated and excluded. She made a good recovery and a post-operative colonoscopy looking for other areas of eosinophilia was normal.

[Acute abdomen caused by eosinophilic enteritis: six observations]

BACKGROUND

Eosinophilic enteritis is a rather rare condition characterized by infiltration of the gastrointestinal tract by eosinophils; as a casue of acute abdomen it is really exceptional. The etiology is unclear and its description in the literature is sparse, but associations have been made with collagen vascular disease, inflammatory bowel disease, food allergy and parasitic infections as it was confirmed in one of our pathologic studies.

CLINICAL CASES

From 1997 to 2011 six cases of eosinophilic enteritis that involved a small bowel segment were diagnosed. A partial resection by an irreversible necrosis was necessary in three of them; in the other three only a biopsy was necessary due to the inflammatory aspect of the affected loop causing the acute abdomen.

CONCLUSIONS

Eosinophilic enteritis can originate acute abdomen processes where an urgent surgical treatment is necessary. The intraoperative aspect can be from a segment of small bowel with inflammatory signs up to a completely irrecoverable loop, where removing of the affected segment is the correct treatment, which can be done laparoscopically.

Olfactory changes after endoscopic sinus surgery in patients with chronic rhinosinusitis

OBJECTIVE

To address the controversy over whether olfactory function is improved or not after endoscopic sinus surgery (ESS) in patients with eosinophilic (ECRS) and non-eosinophilic chronic rhinosinusitis (non-ECRS).

METHODS

Between June 2006 and March 2012, 89 adult patients with CRS underwent ESS at Hyogo College of Medicine. There were 55 men and 34 women with a mean age of 53 years old, ranging from 23 to 79 years. The average follow-up period was 10.7 months (3-24) after ESS. Peripheral blood examination, sinonasal CT imaging, and four kinds of olfaction tests [self-administered olfaction test (SAOQ), visual analog scale (VAS), T&T recognition threshold tests (T&T) and intravenous olfaction test using prosultiamine] were performed. We diagnosed ECRS when (i) symptoms of nasal congestion and olfactory disorder, (ii) bilateral chronic rhinosinusitis with nasal polyps (CRSwNPs), (iii) peripheral blood eosinophilia (>7.0%), and (iv) ethmoid sinus dominant opacification in preoperative CT findings (i.e. ethmoid sinuses (E) were more bilaterally occupied than those of maxillary sinuses (M), E/M≥1), were completely fulfilled. We divided the patients into two groups of ECRS (group A) and non-ECRS (group B). Olfaction tests before operation, and at the 3rd, 6th, 12th, and 24th month postoperation were analyzed. The severity and therapeutic evaluation of olfaction were based on criteria of T&T recognition thresholds.

RESULTS

The mean SAOQ and VAS scores showed significant improvement within 6 months after ESS in both group A and group B. In total, the improvement rates were 52.0% (26/50) at 3 months, 58.5% (24/41) at 6 months, 40.5% (15/37) at 12 months, and 41.2% (7/17) at 24 months. The significant improvement of T&T recognition thresholds in group B was maintained for 24 months, whereas those in group A, showing transient improvement, deteriorated after 12 months or more. A significant difference in postoperative T&T recognition between groups A and B was found at the 12th postoperative month. In both A and B, 84% of patients had a response to prosultiamine (positive group) in the preoperative stage. T&T thresholds in the positive group were significantly better that those in the negative groups in the postoperative stage.

CONCLUSION

Olfactory disorders due to ECRS showed transient improvement that deteriorated as time passed after surgery. The olfaction in the non-ECRS patients recovered comparatively well. Postoperative olfactory results were unfavorable in patients without a preoperative reaction to prosultiamine.

Resolution of eosinophilic gastroenteritis after resection of uterine leiomyomas

Eosinophilic gastrointestinal disorders (EGIDs) primarily affect the gastrointestinal tract. EGIDs have a broad spectrum of presentations, characterised by prominent eosinophilic infiltration through a variable depth in the gastrointestinal tract in the absence of a known cause for eosinophilia. EGIDs include eosinophilic oesophagitis, eosinophilic gastritis, eosinophilic gastroenteritis, eosinophilic enteritis and eosinophilic colitis. Here, we report EGID in a woman who had co-existing uterine leiomyomas. Her EGID resolved after resection of the leiomyomas. She remained asymptomatic on follow-up 13 months after the myomectomy, with resolution of the eosinophilic infiltrate in the gastrointestinal tract.

[Eosinophilic cystitis: review of nine cases]

BACKGROUND

Eosinophilic cystitis is a rare inflammatory pathology. It remains a poorly understood entity.

AIM

To report a series of adult cases of eosinophilic cystitis mimicking a bladder tumor.

METHODS

Retrospective study of cases of eosinophilic cystitis collected in an urology department.

RESULTS

Diagnosis was established on a spontaneous bladder perforation in one case and on hematuria in the eight other cases. Histopatholgy studies confirmed the diagnosis. Eight patients underwent an endoscopic resection of bladder lesions followed by medical therapy with nonsteroidal anti-inflammatory drugs and cortimoxazole. An ileal bladder enlargement was performed in one case. Regular follow-up didn't reveal any recurrence.

CONCLUSION

Eosinophilic cystitis is a rare disease simulating a tumor of bladder. Its clinical presentation is not specific and final diagnosis is based on pathology. Endoscopic resection will help to pathologic diagnosis. Associated to corticoids and antihistaminic drug endoscopic resection constitute the treatment of choice.

Eosinophilic appendicitis caused by Schistosoma japonicum: a case report and review of the literature

Parasitic appendicitis is uncommon. The authors reviewed the pathology of 4,130 appendices resected over the past 10 years (2000 to 2009). Only one case of eosinophilic appendicitis caused by Schistosoma japonicum was identified. The overall prevalence of schistosomal appendicitis was 0.024%. The case was a 61-year-old woman who presented with right lower quadrant abdominal pain. She had been a farmer in Chumphon and Surat Thani Provinces, which are endemic for schistosomiasis in Thailand. Physical, laboratory and ultrasound examinations were suggestive of acute appendicitis. She underwent emergency appendectomy. Intraoperative findings revealed a ruptured appendix with a fecalith in the appendiceal lumen. The histopathologic diagnosis was suppurative eosinophilic appendicitis with schistosomal ova in the mucosa, submucosa, muscular layer and vascular lumens, identified as S. japonicum eggs. The patient was treated for the parasite with praziquantal. We briefly review the clinicopathologic features and pathogenesis of schistosomal appendicitis.

[Eosinophilic cholecystitis: a case report.]

Eosinophilic cholecystitis is a rare disease with clinical presentation similar to acute cholecystitis. The diagnosis is based on typical symptoms of acute cholecystitis with presence of more than 90% eosinophilic infiltration within the gallbladder wall. The case of a 27-year-old woman with periodic epigastric pain during ten years is presented. Routine and Boyden s technique biliary ultrasounds were normal. Hepatobiliary scintigraphy showed delayed gallbladder empty and patient underwent endoscopic sphinterotomy. Laparoscopic cholecystectomy was performed with uneventful postoperative course. Histopathologic examination of the gallblader demonstrated infiltration with eosinophils, consistent with acute eosinophilic cholecystitis.

Furuncular myiasis in a child caused by Wohlfahrtia magnifica (Diptera: Sarcophagidae) associated with eosinophilia

We report the case of an eight-year-old boy with hypereosinophilia who presented with a swelling under his right armpit that had persisted for more than four weeks. A second-stage larva of Wohlfahrtia magnifica was found, leading to the diagnosis of cutaneous myiasis. Following removal of the larva, the clinical and hematological manifestations returned to normal. Diagnosis of myiasis should always be kept in mind in the event of clinical signs of furuncular lesions, which may be accompanied by eosinophilia.

Castleman-like reaction due to toxic substance ingestion

Castleman disease (CD) is an uncommon lymphoproliferative disorder with a unique histopathology. Generally diagnosis is not difficult for an experienced pathologist. However, not usually, some histopathological entities or tissue reactions may mimic CD. Here CD-like reaction due to toxic substance ingestion has been presented.

Eosinophilic enteritis: CT features

We report CT features of four cases of Eosinophilic enteritis. The disease involves the jejunum in one case, the ileum in two cases, and the colon in the remaining case. Two cases demonstrate a predominantly mucosal type of eosinophilic enteritis, while the other two cases demonstrate a predominantly subserosal type. CT findings include bowel wall thickening in four cases, bowel fold thickening in two cases, layering of the bowel wall in two cases, luminal narrowing without obstruction in three cases, an intra-luminal granuloma mimicking a huge polyp in one case, an extra-luminal irregular granuloma markedly enhancing and slightly necrosing in one case, mesenteric lymphadenopathy with peripheral rim-like enhancement and marked necrosis in one case and ascites in one case. CT findings are more characteristic of an inflammatory disease rather than of a tumor, and these findings are helpful for assessing the extent and location of the disease. Moreover, combined with its typical clinical manifestations, CT findings may lead to the correct diagnosis.

Ileocolonic ulcer treated by endoscopic application of collagen-polyvinylpyrrolidone

Ulceration is a complication that may occur after an ileocolonic anastomosis. Most of the etiologies remain speculative. The case of a 33-year-old woman with eosinophilic colitis is reported, in whom a colectomy with an ileocolonic anastomosis was performed. After four months, the patient presented with a stenosis in the ileocolonic anastomosis, necessitating surgical restoration. Four weeks later, the patient presented with rectal bleeding, and a colonoscopy showed an ulcer in the anastomosis. Collagen-polyvinylpyrrolidone was applied into and on the surface of the ulcer, and five days later the procedure was repeated. Follow-up endoscopies at seven days and three months showed complete healing of the ulcer and the patient remained without bleeding throughout a further four weeks of follow-up tests. It was concluded that this biological product could be an excellent treatment for these lesions.

Eosinophilic cystitis induced by bacillus Calmette-Guerin (BCG) intravesical instillation

Eosinophilic cystitis is a rare and uncommon inflammatory bladder disease, in which the pathophysiology is unclear; only a few cases of such disease induced by intravesical instillations have been described. We report a case of eosinophilic cystitis after intravesical bacillus Calmette-Guerin (BCG) instillation for nonmuscle-invasive transitional cell carcinoma of the bladder. To our knowledge, this report is the first case of eosinophilic cystitis induced by intravesical BCG therapy.

Eosinophilic colitis

Eosinophilic colitis is a rare chronic inflammatory bowel condition of unknown etiology. We report a case of cecal volvulus causing obstruction in a patient with eosinophilic colitis. A 48-year-old lady presented with abdominal pain, constipation, and abdominal distension. Clinically and radiologically, she was diagnosed to have cecal volvulus. Preoperative colonoscopic reduction failed. At laparotomy, a right hemicolectomy with primary anastomosis was undertaken. Histology of the resected specimen showed diffuse eosinophilic infiltration suggesting eosinophilic colitis. To the best of our knowledge, this association has been never reported.

Eosinophilic ulcer of the oral mucosa versus squamous cell carcinoma

Eosinophilic ulcer of the oral mucosa is a benign, rare, self-limiting, and generally asymptomatic lesion that shows spontaneous regression. Its etiopathogenesis is still uncertain, but trauma seems to play a fundamental role in the occurrence of this tumor. Clinically, this lesion manifests as an isolated ulcer preferentially located on the tongue, showing a raised and indurated border in addition to a white or yellowish bed. Microscopically, eosinophilic ulcer is characterized by an inflammatory infiltrate rich in leukocytes. Since these lesions show spontaneous cure, treatment becomes unnecessary, but in certain cases, cure is obtained by excision of the ulcer during biopsy. In these cases, the differential diagnosis with squamous cell carcinoma is made. A case of very small eosinophilic ulcer of the oral mucosa located on the lateral border of the tongue is presented.

Budesonide for the treatment of obstructive eosinophilic jejunitis

Eosinophilic gastroenteritis is a rare gastrointestinal (GI) disorder of undetermined origin, characterized by infiltration of eosinophils in the GI tract. Different layers of the bowel wall can be involved and the clinical outlook depends on the area affected. Our subject is a male patient in whom the disease involves the muscular layer causing obstructive jejunitis. The diagnosis was made after surgical resection. A relapse was subsequently treated with short-term intravenous steroids followed by oral budesonide for three months. Treatment was effective with no apparent side effects.

Clonorchiasis-associated perforated eosinophilic cholecystitis

Clonorchiasis, a disease caused by infection with Clonorchis sinensis, is endemic in the Far East. Cholelithiasis, pyogenic cholangitis, cholecystitis, and biliary tract obstruction are common complications of chronic infection. Although cholecystitis caused by clonorchiasis is common, it is rarely reported as resulting from eosinophilic infiltration. We report a rare case of clonorchiasis-associated perforated eosinophilic cholecystitis and review the relevant literature.

Non stenotic food impaction due to eosinophilic esophagitis: a potential surgical emergency

AIM

Eosinophilic esophagitis (EoE) is an emergent condition in which a mucosal infiltrate of > 20 eosinophils per high power microscopic field is accompanied by motor disturbances that may cause food impaction in the absence of esophageal stricture. We report a series of such cases to point out the potential involvement of pediatric surgeons in diagnosis and treatment. Furthermore, data on the motor function of the esophagus investigated manometrically is included.

MATERIAL AND METHODS

Thirteen patients with EoE were referred to our emergency room for acute food bolus impaction. Their median age at diagnosis was 12 years (range 7.6-14.4). History of allergy, endoscopy with biopsy and esophageal function (24-h combined ambulatory manometry with simultaneous pH-metry) were investigated.

RESULTS

In 7 patients emergency endoscopic extraction of the impacted bolus was necessary. Allergic tests were positive in eight patients. The pH probe showed gastroesophageal reflux in two cases. Upon endoscopy, typical features of EoE (esophageal trachealization and whitish papular exudates) were found. Ambulatory 24-h manometry revealed abnormal motility of the distal esophagus with strikingly high amplitudes (> 150 mmHg) and long duration (> 7 sec) of the waves, particularly during the night. Six patients responded rapidly to steroids and/or antiallergic treatment. The remaining patients had a good outcome with dietary treatment alone.

CONCLUSIONS

EoE is an emergent condition that may involve the pediatric surgeon in both the diagnosis and treatment. Typical endoscopic findings and biopsy are required for proper diagnosis. Ambulatory manometry reveals a marked propulsive dysfunction that explains impaction. This dysfunction is reversible, since the symptoms usually disappear with steroids or antiallergic treatment.

Eosinophilic gastroenteritis presenting as acute abdomen

Many causes of acute abdomen are diagnosed on computed tomography (CT). We present two cases of eosinophilic gastroenteritis that showed mural thickening of the stomach, duodenum, and/or proximal jejunum on CT. The correct diagnosis was made by checking the eosinophil count, and, in one case, unnecessary surgery was avoided.

Obstruction of equine small intestine associated with focal idiopathic eosinophilic enteritis: An emerging disease?

Idiopathic focal eosinophilic enteritis (IFEE) is a rare disease in the horse and few cases have been reported in the literature. The objective of this paper was to describe the clinical, surgical, histological features and post-operative progress of 12 horses with IFEE, a disease that had not been identified in the authors' hospital population prior to 2000. Diagnosis of IFEE was made at laparotomy and confirmed by histological examination of resected abnormal small intestine. In all 12 horses colic was associated with jejunal obstruction involving visibly striking and palpably thickened serosal plaques or circumferential constrictions. Surgical resection of affected intestine was performed in 10 horses, of which seven completely recovered. In one horse, on which surgical resection was not performed, ingesta re-obstructed post-operatively at one of the lesions. Histological examination of resected intestines revealed, in all cases, severe transmural enteritis in which eosinophilic leucocytes were the predominant inflammatory cells. No helminths were identified and the cause of this lesion is not known. IFEE is an uncommon but significant cause of small intestinal obstruction for which surgical resection can be curative. The gross lesions may be under-recognised and histology is essential for diagnosis.

Recurrent acute pancreatitis due to eosinophilic gastroenteritis. Case report and literature review

CONTEXT

Eosinophilic gastroenteritis is characterized by eosinophilic infiltration of any gastrointestinal segment from the esophagus to the rectum, most commonly, the stomach and the duodenum. Clinical manifestations range from non-specific gastrointestinal complaints to more specific symptoms such as protein-losing enteropathy, malabsorption, luminal obstruction and eosinophilic ascites.

CASE REPORT

We report the case of a 35-year-old woman with recurrent gastric outlet obstruction due to eosinophilic infiltration of the stomach and the duodenum. There was a history of two episodes of acute pancreatitis as well as eosinophilia of bone marrow and ascites.

CONCLUSIONS

Although unusual, eosinophilic gastroenteritis may be complicated by symptomatic acute pancreatitis. Seven previous cases have been reported in the literature, and a comparison was made. The pancreatitis is probably due to duct obstruction, but some cases of eosinophilic gastroenteritis have pancreatic tissue eosinophilia. Most cases respond to medical treatment, and surgery is usually unnecessary.

Cochlear implantation in a patient with eosinophilic otitis media

Eosinophilic otitis media is an intractable middle ear disease with gelatinous mucoid fluid containing eosinophils associated with bronchial asthma and nasal allergy that sometimes induces deterioration of sensorineural hearing loss. Here, we report a case of eosinophilic otitis media in a 50-year-old woman who received a Nucleus 22 multi-channel cochlear implant in the right ear at the age of 42 years. She had received treatment for bronchial asthma, chronic sinusitis with nasal allergy and otitis media with effusion since the age of 30 years and had noted bilateral sudden deafness and vertigo at the age of 35 years. Preoperative CT and MRI showed cochlear ossification in the left ear, in which mastoidectomy was performed as treatment of eosinophilic otitis media. Long-term follow-up revealed that cochlear implant is indicated for deafness induced by eosinophilic otitis media, and an early decision for cochlear implant surgery is necessary. Steroid administration was remarkably useful in controlling eosinophilic otitis media in patients with bronchial asthma and chronic sinusitis with nasal allergy.

Fallbericht zur Differenzialdiagnose der gastroösophagealen Refluxkrankheit: die eosinophile Ösophagitis

We report on a 22-year-old man with dysphagia and repeated bolus impaction in the esophagus for 10 years. Bolus impactions were frequently mobilised using an endoscope. At endoscopy, esophagitis IV degrees was described. After treatment with omeprazol there was no improvement. The patient was submitted to our hospital for fundoplication. pH-metry demonstrated an increased reflux. At endoscopy of the esophagus, we found red stripes which did not show the typical appearance of erosions. Manometry and X-ray films of the esophagus did not reveal any pathological findings. In combination with anamnesis, symptoms, and endoscopy, the diagnosis of eosinophilic esophagitis was documented by histology. After administration of oral corticosteroids a rapid improvement of the clinical symptoms was observed. The diagnosis of eosinophilic esophagitis should be kept in mind in patients with chronic symptoms of gastroesophageal reflux persisting despite medical therapy, pathological pH-metry and repeated bolus impactions.

Fungus-like sinusitis

Fungus-like sinusitis is also called eosinophilic mucin rhinosinusitis (EMRS). This terminology is purely descriptive and refers to a rhinosinusitis, whose clinical presentation and imaging are similar to those of a noninvasive fungal sinusitis but in which fungus could not be demonstrated pathologically using the conventional silver staining technique or on culture. The authors report 2 clinical cases and recall the diagnostic criteria for the different forms of fungal sinusitis in immunocompetent patients.

Cerebral toxocariasis: a possible cause of epileptic seizure in children

INTRODUCTION

Toxocariasis is a worldwide human helminthiasis, which is mostly asymptomatic and caused by toxocara canis, a roundworm in dogs. These can cause visceral larva migrans syndrome in humans who ingest contaminated soil. CNS manifestation with a focal mass lesion is very rare, seizures often being the first symptom.

CASE REPORT

We describe an 11-year-old girl presenting with a generalized epileptic seizure and eosinophilia in blood. Under antibiotic therapy under the assumption of toxoplasmosis the lesion did not decrease and surgical resection was considered. We used computer-assisted surgery (CAS) for careful tissue resection. Postoperatively the diagnosis of toxocariasis was confirmed and albendozole medication was administered for 7 days. The patient developed well without neurological deficits or seizures.

CONCLUSION

We conclude that although neurological involvement is rare in toxocariasis, a cerebral infection in a child with epileptic seizures and eosinophilia should be considered.

The effect of nasal packing and prednisolone on mucosal healing and reciliation in a sheep model

STATEMENT OF PROBLEMS

To determine whether topical prednisolone affected sinus mucosal healing in a sheep animal model.

METHODS OF STUDY

A standardised sheep model with concurrent Oestrus ovus infection was utilised. Following full thickness nasal mucosal injuries, hyaluronic acid packs soaked with prednisolone were applied to one side of the nasal cavity, with hyaluronic acid packs without prednisolone, to the other. At four weekly intervals, for 16 weeks, mucosal biopsies were taken and analysed for epithelial thickness and length, for cilial height and percentage of ciliated mucosa and mucosal inflammation.

RESULTS

Eighteen sheep were utilised, with each acting as its own control. At completion of the study there was no statistical difference between the control or treatment group for the percentage of mucosal epithelialisation (mean: 86.5% vs 92.2%), epithelial thickness (mean: 39.7 microns vs 39.3 microns or the percentage of epithelium ciliated (mean: 26.5% vs 30.8%). Furthermore prednisolone had no effect on mucosal inflammation with the control arm mean score of 3.44 (SD .022) and treatment arm mean of 3.77 (SD 0.21).

CONCLUSION

Hyaluronic acid nasal packs soaked in prednisolone failed to improve the speed of mucosal healing or re-ciliation in the sheep model of eosinophilic rhinosinusitis.

Laparoscopy in eosinophilic jejunitis presenting as subacute bowel obstruction: a case report

Eosinophilic gastroenteritis is rare, seen in approximately 1 in 10,000 hospital admissions. The diagnosis is often retrospective and histopathological. Abdominal pain and obstructive symptoms associated with weight loss are the usual presenting complaints. We report a patient with symptoms of proximal bowel obstruction in whom diagnosis could not be made with conventional radiology and endoscopy. Laparoscopy showed that an intensely thickened proximal jejunum to be the cause of the obstruction. A laparotomy and resection anastomosis were done. The biopsy showed eosinophilic jejunitis. The patient did well post-operatively. The literature of this disease entity has been reviewed. Full-thickness laparoscopic biopsy and a course of steroids might avoid a laparotomy in these patients.

Chronic subdural haematoma and the enigmatic eosinophil

The membranes from 50 cases of chronic subdural haematomas were examined histologically and correlated with the duration of the lesion. Cases were divided into three groups based on duration from time of trauma and/or onset of clinical symptoms to date of surgery - Group I: 1 to 30 days, Group II: 31 to 90 days and Group III: >90 days. Infiltration with eosinophils was observed in the vascularised and hyalinised granulation tissue of the subdural membrane in 30 of the 50 cases (60%). There was a trend to correlation both of the frequency and the extent of eosinophilic infiltration with duration of haematoma. Thus, eosinophils were encountered in about half the cases with duration up to 3 months which increased to 80% in cases with duration more than 3 months. The extent of eosinophilic infiltration (mild, moderate or severe) also appeared to correlate with duration of haematoma in that mild infiltration was more common in Group I cases while moderate to severe infiltration were more frequently observed in Group II and III cases. No correlation was observed of the eosinophilic infiltrate with age and sex of the patients or with presence of other cellular inflammatory components of the membrane. Interestingly, a finding hitherto unreported in English literature was the demonstration of mast cells in 7 of 16 membranes (44%) which had been stained using toluidine blue. It is possible that the eosinophils appear at this unusual site due to chemotactic stimulus abetted by these mast cells as well as lymphocytes and haemosiderin pigment. The eosinophils may have an important role in the repair and healing process of these membranes.

[Investigations on allergic fungal genesis of chronic rhinosinusitis]

BACKGROUND

The incidence of allergic fungal sinusitis (AFS) is estimated differently. The importance of hyphal findings in nasal mucus for initiation of chronic hyperplastic sinusitis is not proven.

METHODS

124 patients with clinical signs and CT-scan findings of a chronic-hyperplastic rhinosinusitis were treated by functional endoscopic sinus surgery. During the operation a thick mucus was found in each patient. The mucus was isolated and investigated by histopathological analysis with special Grocott-stain and a culture for fungal growth was initiated. Furthermore the diagnostic for allergic reactions against fungus was done by prick- and RAST-tests.

RESULTS

21 patients had positive histopathological findings of fungus. In 10 cases fungal hyphae were found embedded in typical eosinophilic mucus. A positive allergic reaction against fungus was seen in 7 of these 10 patients. The culture results showed different pictures according to the isolated species, in 3 cases of the 10 AFS cases the culture was negative. The other 11 cases of 21 positive histological findings of fungus were cases of a fungus ball. The other 103 patients were without any sign for fungus in the HE- or Grocott-stain.

CONCLUSIONS

A high incidence of AFS is not evident in group of chronic hyperplastic rhinosinusitis. The presence of eosinophilic "allergic" mucus is not the evidence for AFS. The inflammatory cascade leading to the clinical picture is a multifactorial event. The role of detectable fungus hyphae have to be estimated by further investigations.

A case of calvarial eosinophilic granuloma with rapid expansion and wide skull invasion: immunohistochemical analysis of Ki-67

A 15-year-old male visited our neurological service with progressive occipitalgia. Computed tomography showed an osteolytic lesion at the occipital cranium, which grew rapidly during a month. Magnetic resonance imaging showed the lesion as low intensity on T1- and high intensity on T2-weighted images. The mass was soft and successfully removed with surrounding cranium. Histological examination revealed an eosinophilic granuloma with wide skull invasion. Immunohistochemical analysis on the specimen disclosed Ki-67 expression with labeling index of 6.2%. Relatively high proliferative activity in the present case indicates that the local replication of Langerhans' cells as well as inflammatory response contributes to the expansion of calvarial eosinophilic granuloma. This is the first report demonstrating the result of Ki-67 expression on calvarial eosinophilic granuloma.