Case Study Details Challenges in Eosinophilic Gastritis Management

Eosinophilic gastritis (EG) is a rare inflammatory disease that often manifests as nonspecific clinical symptoms, and it can be difficult to diagnose and manage. A recent case study published in Clinical Case Reports examined a patient living with EG and addressed the clinical signs and diagnostic challenges EG presents.

EG is one of 5 types of eosinophilic gastrointestinal disorders (EGIDs), each of which affects a distinct part of the GI tract—and it is the least common. It involves eosinophilic infiltration in any layer of the stomach wall and a lack of identifiable causes of eosinophilia. EG diagnosis requires endoscopy and biopsy, with a histopathological examination (HPE) showing an eosinophil count of 30 per high-power field (HPF) or higher and no known cause of eosinophilia.

The case report involved a 65-year-old female patient who presented with consistent pain in the left upper abdomen for 2 months and who had multiple vomiting episodes. She had lost approximately 5 kg (11 lb) of body weight due to pain associated with food consumption and subsequent restricted food intake. Her medical history was not significant for her current symptoms and did not include any allergic conditions such as asthma, atopic dermatitis, allergic rhinitis, food intolerance, or known drug allergies. She did not report any fever, night sweats, or skin lesions.

Two months prior to her evaluation by the case report authors at Kathmandu Medical College Teaching Hospital in Nepal, she was evaluated at a different center and presented with the same complaints. At the initial visit, an upper gastrointestinal endoscopy (UGIE) showed an ulcer in the antrum, but HPE was not performed. A clarithromycin-based Helicobacter pylori regimen was prescribed, but her symptoms worsened, and she was then prescribed a levofloxacin-based H pylori regimen. Her vital signs were stable at examination, and no lymphadenopathy, hepatosplenomegaly, or ascites were noted. A hemogram showed a hemoglobin level of 9.1 gm%, normal leucocyte counts, and an absolute eosinophil count of 147/mm³.

The large ulcer was still present at the time of secondary examination, which included another endoscopy and collection of multiple tissue biopsies for HPE. Fecal occult blood testing was positive, and a CT scan of the abdomen showed focal and asymmetrical thickening of the wall along the lesser curvature of the stomach that measured 6.5 mm and was 2.6 cm in length.Chronic active ulcerative inflammation of the antral mucosa and infiltration of lamina propria with eosinophils—which measured 54 per HPF—as well as lymphocytes and plasma cells, were found in the HPE. No H pylori–like organisms were found, and the HPE results suggested EG.

Further tests, including stool examinations, urinalysis, colonoscopy, chest radiographs, connective tissue disorder tests, and liver and renal function examination all returned unremarkable results. A proton pump inhibitor and 40 mg of prednisone daily for 4 weeks were prescribed, followed by 4 weeks of tapering. After 8 weeks, complete ulcer remission was shown on a UGIE.

This case highlights the nonspecific nature of EG symptoms, considering the patient presented with abdominal pain, vomiting, and anemia. “At presentation, our working diagnosis was chronic gastritis with a suspicion of malignancy based on age, chronicity, nonspecific symptomatology, and no response to prior treatment with clarithromycin and consecutive therapy with levofloxacin-based H pylori regimen,” the authors wrote. “Further workup revealed a large antral ulcer with eosinophilic infiltration into the lamina propria (54/HPF), characteristic of the mucosal type of EG.”

The characteristics of this case make it rare, the authors noted, and a misdiagnosis would lead to surgical intervention for nonresolving gastritis and suboptimal results for the patient. In this case, ruling out other potential causes of eosinophilic infiltration of the gastric mucosa is also important. Therefore, detailed examinations of patient history and current symptoms are needed to accurately diagnose EG. Steroids and dietary modifications are known to be effective for symptomatic management, which the patient responded well to in this case.

“Despite the lack of enough evidence for the role of steroids and dietary modifications, we used steroids, to which a dramatic response was observed, along the lines of existing literature and supporting our diagnosis of EG despite the absence of peripheral eosinophilia and atopy. Our finding parallels the existing literature on the use of steroids in the management of EG,” the authors wrote.

Overall, the case highlights the importance of endoscopic investigation and HPE when persistent GI symptoms do not respond to treatment.

Reference

Mishra A, Bhattarai TR, Mishra A, Poudel S. Eosinophilic gastritis without peripheral eosinophilia and atopy: a case report. Clin Case Rep. Published online June 27, 2022. doi:10.1002/ccr3.6005