Additional Symptoms in Eosinophilic Diseases Call for Increased Evaluations

Researchers recently described a case of an adult male with eosinophilic esophagitis (EoE) who was later received an eosinophilic colitis (EC) diagnosis, which is less common than EoE.

The researchers said they wrote about the case in order to highlight that when dealing with eosinophilic gastrointestinal diseases (EGIDs), “patients with EoE and new GI symptoms require a high index of suspicion for the involvement of distal segments of the GI tract.”

EGIDs are a group of inflammatory conditions that cause the accumulation of eosinophils in the GI tract without a known secondary cause. The diagnosis and management of EGIDs are challenging due to nonspecific symptoms and manifestations that can easily mimic other conditions.

The overall prevalence of EoE is about 25.9 per 100,000 persons, while for eosinophilic gastroenteritis (EGE) and EC it is estimated to be 5 and 2 per 100,000 persons, respectively.

In this case, the patient received his EoE diagnosis at age 28; he had a history of asthma, allergic rhinitis, and gastroesophageal reflux disease. At the time of diagnosis, he presented with dysphagia and reflux, but improved slightly after proton pump inhibitor therapy. An initial esophagogastroduodenoscopy (EGD) found a ringed esophagus with 2 dominant rings in the upper and middle esophagus, and a tissue biopsy showed more than 50 eosinophils per high-power field (eos/hpf), consistent with EoE.

A 3-month course of topical fluticasone (220 mcg twice daily) along with dexlansoprazole 60 mg and an intermittent 4-food elimination diet gave some relief. He did not respond to a higher dose of swallowed fluticasone 440 mcg twice daily.

Symptoms persisted, including dysphagia, reflux, and choking sensations, and he required EGDs and dilatations 2 to 3 times per year. As the disease advanced, he experienced chronic diarrhea and abdominal cramping, which led him to be evaluated for EGE and EC at age 33.

A repeat EGD with a colonoscopy showed a ringed esophagus with longitudinal furrows and exudates without strictures, as well as a 3-mm polyp in the sigmoid as well as granular mucosa and edema surrounding the appendiceal orifice.

On histopathology, samples taken from the esophagus revealed more than 80 eos/hpf, consistent with EoE, and biopsies from the ascending colon showed eosinophils in the lamina propria and epithelium above 100 eos/hpf.

He was given an EC diagnosis, and soon afterward he received a 10-day course of oral steroids for pneumonia caused by SARS-CoV-2. The steroids relieved his diarrhea and cramping, giving additional confirmation for an EC diagnosis.

The authors said the case shows that EGIDs "require both clinical and histological investigation for diagnosis, highlighting the importance of luminal examination with endoscopic biopsies."

The report has some limitations. Testing for systemic parasitic infections was not completed, and short-term follow-up precludes the ability to understand long-term outcomes. The patient also did not adhere to a 6-food elimination diet, and he was treated mainly with serial dilations instead of a step-up or step-down approach to pinpoint the primary food trigger.

Reference

Hasan LZ, Vecchio E, Wu Q, Goldenberg SA, Rezaizadeh H. Eosinophilic esophagitis with subsequent eosinophilic colitis: keeping a high index of suspicion. Cureus. Published online February 9, 2022. doi:10.7759/cureus.22073