Diagnostic Radiology

barium column, dilatation of isolated proximal jejunal segments, and increased width of the mucosal folds (Fig. 2). Acute abdominal pain and hematemesis occurred immediately following small bowel and gastric biopsies on May 26 (Figs. 3 and 4). The hemorrhage was treated, but he died of cardiac arrest the same day. Postmortem examination demonstrated classic polyarteritis nodosa involving primarily the medium-sized vessels of the mesentery, liver, and heart with well-advanced, typical fibrinoid necrosis of the muscular arteries. The microscopic sections ofthe stomach showed heavy round cell infiltrate in the mucosa, primarily of plasma cells. Eosinophils were not prominent. The small bowel showed decreased size and thickening of the villi with a slight increase in plasma cell infiltrate in the mucosa .

Polyarteritis Nodosa "Mimicking" Eosinophilic Gastroenteritis 1 Andrew J. Nicks, M.D. and Felix Hughes, M.D.2

This case of a 71-year-old man with persistent eosinophilia (33-54%), intermittent abdominal pain, and transient pulmonary infiltrates illustrates how polyarteritis nodosa may mimiceosinophilic gastroenteritis. The radiographic manifestations andclinical findings of bothare similar. INDEX TERMS: Eosinophilia.Gastrointestinal tract. Periarteritis, Stomach, inflammation

nodosa s

Radiology 116:53-54, July 1975


Polyarteritis nodosa can present with a roentgenographic, laboratory, and clinical picture similar to eosinophilic gastroenteritis.

The roentgenologic appearance of eosinophilic gastroenteritis, has been described as a diffuse gastric, pyloric, and small bowel abnormality. Gastric involvement is usually restricted to the antral area, evidenced by irregular narrowing, enlargement of mucosal folds, "cobblestone pattern," polypoid filling defects, and pyloric obstruction. Small bowel abnormality may include regular nodular contour defects, "sawtoothed" pattern, effaced volvulae, and luminal narrowing and widening of bowel segments if the mesentery is involved. In malabsorption, the barium column may be somewhat segmented and flocculated (3, 9, 10). Treatment of eosinophilic gastroenteritis is conservative and consists of systemic steroid therapy. The roentgen signs may disappear within a few months after initiation of treatment (12, 14). In polyarteritis nodosa, the roentgen changes are caused

A 71-year-old Filipino man was first seen at Letterman Army Medical Center in November 1968 with anemia and an eosinophilia of 43 % which has persisted between 33 and 54 % ; platelets 800,OOO/mm3 ; and hematocrit 29-35 %. Radiologic evaluation revealed four separate pulmonary infiltrates from Jan. 1970 to May 1971, Three weeks prior to admission on 12 May 1971, dysphagia and diffuse abdominal pain developed. Upper gastrointestinal (Gl) series was negative. Laboratory data: hematocrit 24 %; platelets, 430,OOO/mm 3 ; white blood cells, 2,900/mm3 with a differential of 46 % neutrophils, 17 % lymphocytes, and 36 % eosinophils. Bone marrow aspirate was consistent with sideroblastic anemia with a high normal number of eosinophils. Twenty-four hours after admission, abdominal pain subsided, but recurred three days later and again subsided within 24 hours. An upper GI series on May 19 showed delayed gastric emptying and irregular gastric contour with a "cobblestone appearance" to the mucosa (Fig. 1). Small bowel examination revealed segmentation of the

Fig. 1.

Air contrast view of stomach. Note cobblestone appearance of mucosa.

Fig. 2.

One-hour follow-up film shows dilatation of proximal small bowel and flocculation of barium.

1 From the Department of Radiology (A. J. N., Resident), Letterman Army Medical Center, Presidio of San Francisco, Calif. 94129. Accepted for publication in February 1975. The opinions or assertations contained herein are the private views of the authors and are not to be construed as official, nor as reflecting the views of the Department of the Army or the Department of Defense. 2 Virginia Beach Hospital, Virginia Beach, Va. vb






July 1975

Since the roentgenographic and clinical findings of the two conditions may appear similar, the radiologist should be familiar with the spectrum of both. REFERENCES

Fig. 3. Gastric biopsy. Note heavy round cell infiltrate, primarily plasma cells and focal lymphoid aggregates. Eosinophils are not prominent.

Fig. 4. Small bowel biopsy. Villi are reduced in size and focally thickened. Note increase in plasma cells in lamina propria. by ischemia and inflammation and may be similar to changes seen in eosinophilic gastroenteritis. This is especially true in the presence of malabsorption which occurs in both entities (4, 11, 18). Peripheral eosinophilia and pulmonary infiltrates may be present in both diseases. Numerous reports (1, 2, 6-8, 13, 15, 17, 19-22, 24) describing GI complications of polyarteritis nodosa have appeared in the medical literature. Some complications may present life-endangering abdominal emergencies, e.g., GI hemorrhage, perforation, and infarction. Other complications include small intestinal obstruction, peritonitis, pancreatitis, superior mesenteric artery thrombosis, and ulcerative enterocolitis. Maiolo et al. (16) have shown that early diagnosis and subsequent, properly timed, selective surgery have increased survival in patients with polyarteritis nodosa. If the diagnosis of eosinophilic gastroenteritis is mistakenly made, the potentially correctable lesions of polyarteritis nodosa may be masked if steroid treatment is begun. In addition, the complications of peroral gastric and jejunal biopsy may be increased.

1. Akbarian M: Abdominal apoplexy in polyarteritis nodosa. Report of a case. Am J Dig Dis 11:63-67, Jan 1966 2. Buranasiri S, Baum S, Nusbaum M, et al: Periarteritis of middle colic artery. Arteriographic, surgical, pathological, correlation. Am J Gastroenterol 59:73-76, Jan 1973 3. Burhenne HJ, Carbone JV: Eosinophilic (allergic) gastroenteritis. Am J Roentgenol 96:332-338, Feb 1966 4. Carron DB, Douglas AP: Steatorrhoea in vascular insufficiency of the small intestine. Five cases of polyarteritis nodosa and allied disorders. Q J Med 34:331-340, Jul 1965 5. Castleman B, Kibbee BU: Case records of the Massachusetts General Hospital. Case 4. N Engl J Med 268: 148-153, Jan 1963 6. Couris GD, Block MA, Rupe CE: Gastrointestinal complications of collagen diseases. Surgical implications. Arch Surg 89: 695-700, Oct 1964 7. Craig RD: Multiple perforations of the small intestine in polyarteritis nodosa. Gastroenterology 44:355-356, Mar 1963 8. Debray C, Roge J, Marche M, et al: Le manifestazioni digestive della periarterite nodosa. Minerva Med 60:5305-5318, Dec 1969 9. Edelman MJ, March TL: Eosinophilic gastroenteritis. Am J RoentgenoI91:773-778, Apr 1964 10. Goldberg HI, O'Kieffe D, Jenis EH, et al: Diffuse eosinophilic gastroenteritis. Am J RoentgenoI119:342-351, Oct 1973 11. Gregg JA, Luna L: Eosinophilic gastroenteritis. Report of a case with protein-losing enteropathy. Am J Gastroenterol 59:41-47, Jan 1973 12. Klein NC, Hargrove RL, Sieisenger MH, et al: Eosinophilic gastroenteritis. Medicine 49:299-319, Jul 1970 13. Lee HC, Kay S: Primary polyarteritis nodosa of stomach and small intestine as a cause of gastro-intestinal hemorrhage. Ann Surg 147:714-725, May 1958 14. Leinbach GE, Rubin CE: Is eosinophilic gastroenteritis caused by food allergy? (abst) Gastroenterology 56: 1177, Jun 1969 15. Lindsay MK, Tavadia HB, Whyte AS, et al: Acute abdomen in rheumatoid arthritis due to necrotizing arteritis. Br Med J 2:592593, 9 Jun 1973 16. Matolo NM, Albo D Jr: Gastrointestinal complications of collagen vascular diseases. Surgical implications. Am J Surg 122: 678-682, Nov 1971 17. McKeown KC, Ganguli AK: Gastrointestinal symptoms in polyarteritis nodosa; report of a case. Br J Surg 44:308-312, Nov 1956 18. Meyers MA, Kaplowitz N, Bloom AA: Malabsorption secondary to mesenteric ischemia. Am J Roentgenol 119:352-358, Oct 1973 19. Painter RW: Sequential gastrointestinal complications of polyarteritis nodosa. Am J Gastroenterol 55:383-386, Apr 1971 20. Pugh JI, Stringer P: Abdominal periarteritis nodosa. Br J Surg 44:302-308, Nov 1956 21. Rabinovitch J, Rabinovitch S: Infarction of the small intestine sequent to polyarteritis nodosa of mesenteric vessels. Am J Surg 88:896-901, Dec 1954 22. Rose TF, Fowler NA: Spontaneous perforation of the small bowel: a description of six unusual cases. Med J Aust 2:393-395, 14 Sep 1957 23. Ureles AL, Alsc;:hibaja T, Lodico D, et al: Idiopathic eosinophilic infiltration of the gastrointestinal tract, diffuse and circumscribed; a proposed classification and review of the literature, with two additional cases. Am J Med 30:899-909, Jun 1961 24. Wold LE, Baggenstoss AH: Gastro-intestinal lesions of periarteritis nodosa. Proc Staff Meet Mayo Clinic, 24:28-35, Jan 19, 1949 Technical Publications Editor Letterman Army Medical Center Presidio of San Francisco, Calif. 94129

Polyarteritis Nodosa "mimicking" eosinophilic gastroenteritis.

Diagnostic Radiology • • barium column, dilatation of isolated proximal jejunal segments, and increased width of the mucosal folds (Fig. 2). Acute...
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