ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Grace Elta and Robert J. Fontana, Section Editors
Crystal Clear: A Unique Clue to Diagnosis in a Patient With Recurrent Nausea and Vomiting Shazia Mehmood Siddique and Nisha Aggarwal Gilotra Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
Question: A 36-year-old African-American woman with a history of hypertension, asthma, and ongoing tobacco use presented to our hospital with abdominal pain, nausea, vomiting, and intermittent diarrhea. She had recently been treated for a breast abscess with trimethoprim/ sulfamethoxazole and subsequently admitted to another hospital for acute pancreatitis with lipase of 1314 U/L. Her symptoms improved on discharge; however, she continued to have diarrhea. On admission to our hospital 3 days later, her physical examination was only notable for moderate abdominal tenderness to palpation in the epigastric region without peritoneal signs, and her lipase was elevated at 582 U/L. She was also noted to have a peripheral eosinophilia of 11.3% (total white blood cell count, 7.96 K/mm3; absolute eosinophil count, 900 K/mm3), initially attributed to recent sulfa exposure, which had been hypothesized to cause her pancreatitis given normal hepatobiliary imaging and no history of alcohol intake. The patient’s nausea and vomiting improved with limited oral intake. She did, however, experience intermittent loose bowel movements. Stool studies for ova and parasites were sent. A trichrome stain of stool is shown in Figure A. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.02.043
Gastroenterology 2014;147:e1–e2
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 1: Eosinophilic Gastroenteritis She was noted to have Charcot Leyden crystals in her stool, with negative infectious workup. Charcot Leyden crystals are paired hexagonal pyramids joined at the bases that stain purplish-red on trichome stain. They are produced from the breakdown of eosinophils and consist of lysophospholipase, an enzyme synthesized by eosinophils. Charcot Leyden crystals are observed more commonly in the sputum of asthmatics, but are rarely found in the stool. To our knowledge, this has not previously been described in the literature, in the absence of ova and parasites, aside from a case report in 1989 of hypereosinophilic syndrome.1 Given these findings, she underwent esophagogastroduodenoscopy, which revealed a normal appearing esophagus, several prepyloric clean-based gastric ulcerations, and a normal appearing duodenum. Esophageal, gastric, and duodenal biopsies revealed prominent eosinophils (Figure B). The patient was diagnosed with eosinophilic gastroenteritis and possible eosinophilic pancreatitis. Eosinophilic gastroenteritis is characterized by gastrointestinal eosinophilic infiltration and can present with varied symptoms, depending on the location of infiltration.2 Associated pancreatitis is a rare entity, thought to be caused by duct obstruction but some cases have also found pancreatic tissue eosinophilia.3 She was initiated on oral steroid therapy and instructed to follow the 6-food elimination diet, avoiding peanuts, soy, milk, seafood, eggs, and wheat. On follow-up, she reported improved symptoms, and her eosinophilia decreased to 0.2%. This case illustrates that the identification of Charcot Leyden crystals in stool studies should prompt clinicians to consider endoscopy to evaluate for eosinophilic gastroenteritis. Pancreatitis should also be considered in the setting of eosinophilia, such as in this patient with the relevant symptoms of pancreatitis and elevated lipase, but otherwise negative diagnostic workup for the etiology of pancreatitis. This diagnostic approach can potentially ensure faster diagnosis of an uncommon etiology that has a viable treatment that greatly impacts patient outcomes.
References 1. 2. 3.
e2
Marolda M, Orefice G, Barbieri F, et al. The idiopathic hypereosinophilic syndrome. Clinical, electrophysiological and histological study of a case. Ital J Neurol Sci 1989;10:79–84. Talley N, Shorter R, Phillips S, et al. Eosinophilic gastroenteritis: a clinicopathological study of patients with disease of the mucosa, muscle layer, and subserosal tissues. Gut 1990;31:54–58. Lyngbaek S, Adamsen S, Aru A, et al. Recurrent acute pancreatitis due to eosinophilic gastroenteritis. J Pancreas 2006; 7:211–217.
Crystal Clear: A Unique Clue to Diagnosis in a Patient With Recurrent Nausea and Vomiting Shazia Mehmood Siddique and Nisha Aggarwal Gilotra Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
Question: A 36-year-old African-American woman with a history of hypertension, asthma, and ongoing tobacco use presented to our hospital with abdominal pain, nausea, vomiting, and intermittent diarrhea. She had recently been treated for a breast abscess with trimethoprim/ sulfamethoxazole and subsequently admitted to another hospital for acute pancreatitis with lipase of 1314 U/L. Her symptoms improved on discharge; however, she continued to have diarrhea. On admission to our hospital 3 days later, her physical examination was only notable for moderate abdominal tenderness to palpation in the epigastric region without peritoneal signs, and her lipase was elevated at 582 U/L. She was also noted to have a peripheral eosinophilia of 11.3% (total white blood cell count, 7.96 K/mm3; absolute eosinophil count, 900 K/mm3), initially attributed to recent sulfa exposure, which had been hypothesized to cause her pancreatitis given normal hepatobiliary imaging and no history of alcohol intake. The patient’s nausea and vomiting improved with limited oral intake. She did, however, experience intermittent loose bowel movements. Stool studies for ova and parasites were sent. A trichrome stain of stool is shown in Figure A. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.02.043
Gastroenterology 2014;147:e1–e2
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 1: Eosinophilic Gastroenteritis She was noted to have Charcot Leyden crystals in her stool, with negative infectious workup. Charcot Leyden crystals are paired hexagonal pyramids joined at the bases that stain purplish-red on trichome stain. They are produced from the breakdown of eosinophils and consist of lysophospholipase, an enzyme synthesized by eosinophils. Charcot Leyden crystals are observed more commonly in the sputum of asthmatics, but are rarely found in the stool. To our knowledge, this has not previously been described in the literature, in the absence of ova and parasites, aside from a case report in 1989 of hypereosinophilic syndrome.1 Given these findings, she underwent esophagogastroduodenoscopy, which revealed a normal appearing esophagus, several prepyloric clean-based gastric ulcerations, and a normal appearing duodenum. Esophageal, gastric, and duodenal biopsies revealed prominent eosinophils (Figure B). The patient was diagnosed with eosinophilic gastroenteritis and possible eosinophilic pancreatitis. Eosinophilic gastroenteritis is characterized by gastrointestinal eosinophilic infiltration and can present with varied symptoms, depending on the location of infiltration.2 Associated pancreatitis is a rare entity, thought to be caused by duct obstruction but some cases have also found pancreatic tissue eosinophilia.3 She was initiated on oral steroid therapy and instructed to follow the 6-food elimination diet, avoiding peanuts, soy, milk, seafood, eggs, and wheat. On follow-up, she reported improved symptoms, and her eosinophilia decreased to 0.2%. This case illustrates that the identification of Charcot Leyden crystals in stool studies should prompt clinicians to consider endoscopy to evaluate for eosinophilic gastroenteritis. Pancreatitis should also be considered in the setting of eosinophilia, such as in this patient with the relevant symptoms of pancreatitis and elevated lipase, but otherwise negative diagnostic workup for the etiology of pancreatitis. This diagnostic approach can potentially ensure faster diagnosis of an uncommon etiology that has a viable treatment that greatly impacts patient outcomes.
References 1. 2. 3.
e2
Marolda M, Orefice G, Barbieri F, et al. The idiopathic hypereosinophilic syndrome. Clinical, electrophysiological and histological study of a case. Ital J Neurol Sci 1989;10:79–84. Talley N, Shorter R, Phillips S, et al. Eosinophilic gastroenteritis: a clinicopathological study of patients with disease of the mucosa, muscle layer, and subserosal tissues. Gut 1990;31:54–58. Lyngbaek S, Adamsen S, Aru A, et al. Recurrent acute pancreatitis due to eosinophilic gastroenteritis. J Pancreas 2006; 7:211–217.
