Crystal Clear: A Unique Clue to Diagnosis in a Patient With Recurrent Nausea and Vomiting
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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/mm 3 ; absolute eosinophil count, 900 K/mm 3 ), 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 inter- mittent 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
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Transcript of Crystal Clear: A Unique Clue to Diagnosis in a Patient With Recurrent Nausea and Vomiting
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 RecurrentNausea and VomitingShazia Mehmood Siddique and Nisha Aggarwal Gilotra
Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
Question: A 36-year-old African-American woman with ahistory of hypertension, asthma, and ongoing tobacco usepresented to our hospital with abdominal pain, nausea,vomiting, and intermittent diarrhea. She had recentlybeen treated for a breast abscess with trimethoprim/sulfamethoxazole and subsequently admitted to anotherhospital for acute pancreatitis with lipase of 1314 U/L.Her symptoms improved on discharge; however, shecontinued to have diarrhea.
On admission to our hospital 3 days later, her physicalexamination was only notable for moderate abdominaltenderness to palpation in the epigastric region withoutperitoneal signs, and her lipase was elevated at 582 U/L.She was also noted to have a peripheral eosinophilia of11.3% (total white blood cell count, 7.96 K/mm3; absoluteeosinophil count, 900 K/mm3), initially attributed torecent sulfa exposure, which had been hypothesized tocause her pancreatitis given normal hepatobiliary imagingand no history of alcohol intake.
The patient’s nausea and vomiting improved withlimited oral intake. She did, however, experience inter-
mittent loose bowel movements. Stool studies for ova and parasites were sent. A trichrome stain of stool is shown inFigure 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 interestThe authors disclose no conflicts.
© 2014 by the AGA Institute0016-5085/$36.00http://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: EosinophilicGastroenteritis
She was noted to have Charcot Leyden crystals in herstool, with negative infectious workup. Charcot Leydencrystals are paired hexagonal pyramids joined at the basesthat stain purplish-red on trichome stain. They are pro-duced from the breakdown of eosinophils and consist oflysophospholipase, an enzyme synthesized by eosinophils.Charcot Leyden crystals are observed more commonly inthe sputum of asthmatics, but are rarely found in thestool. To our knowledge, this has not previously beendescribed in the literature, in the absence of ova andparasites, aside from a case report in 1989 of hyper-eosinophilic syndrome.1
Given these findings, she underwent esophagogas-troduodenoscopy, which revealed a normal appearingesophagus, several prepyloric clean-based gastric ulcera-tions, and a normal appearing duodenum. Esophageal,gastric, and duodenal biopsies revealed prominent eo-sinophils (Figure B). The patient was diagnosed with
eosinophilic gastroenteritis and possible eosinophilic pancreatitis. Eosinophilic gastroenteritis is characterized by gastro-intestinal eosinophilic infiltration and can present with varied symptoms, depending on the location of infiltration.2Associated pancreatitis is a rare entity, thought to be caused by duct obstruction but some cases have also foundpancreatic tissue eosinophilia.3 She was initiated on oral steroid therapy and instructed to follow the 6-food eliminationdiet, avoiding peanuts, soy, milk, seafood, eggs, and wheat. On follow-up, she reported improved symptoms, and hereosinophilia decreased to 0.2%.
This case illustrates that the identification of Charcot Leyden crystals in stool studies should prompt clinicians toconsider endoscopy to evaluate for eosinophilic gastroenteritis. Pancreatitis should also be considered in the setting ofeosinophilia, such as in this patient with the relevant symptoms of pancreatitis and elevated lipase, but otherwise negativediagnostic workup for the etiology of pancreatitis. This diagnostic approach can potentially ensure faster diagnosis of anuncommon etiology that has a viable treatment that greatly impacts patient outcomes.
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References
1. Marolda M, Orefice G, Barbieri F, et al. The idiopathic hypereosinophilic syndrome. Clinical, electrophysiological andhistological study of a case. Ital J Neurol Sci 1989;10:79–84.2. 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;31:54–58.3. Lyngbaek S, Adamsen S, Aru A, et al. Recurrent acute pancreatitis due to eosinophilic gastroenteritis. J Pancreas 2006;
7:211–217.
