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| Case of the Week Tuesday13/12/2005 |
Presented by Dr. Marwa Khairy.
Click here to download a power point presentation for the case.
Hypereosinophilic Syndrome
STAFF ROUND PRESENTATION
PROF. DR. AYMAN YOSRY UNIT
PERSONAL HISTORY
Female patient, 36y old.
She ’ s housewife, born and living in Giza .
She ’ s married for 16years with 3 offsprings, the youngest is 9years old.
No special habits of medical importance.
History of contact with canal water, with no antibilharzial ttt received.
Menstrual history:
Menarche at age of 16, with regular cycles (4days/ 28 days), history of contraception 9years ago in the form of injectable hormones for 4years.
Hysterectomy 5years ago following severe menorrhagia not controlled by medications .
COMPLAINT
Persistent vomiting
HISTORY OF PRESENT ILLNESS
The condition started 2 months ago by recurrent attacks of vomiting (4 – 5times daily) preceded by nausea not related to meals and not associated with blurring of vision or headache .
The vomitus was yellowish in colour, malodorous, not bloody with no special contents.
The condition is associated with:
Severe intermittent colicky pain, mainly periumbilical, not improving by antispasmotics drugs, partially improved by vomiting and with no specific radiation.
Constipation; one motion every 2-3days, not associated with tenesmus or dysentery. Insignificant weight loss (3-4 Kg) associated with anorexia.
The condition is not associated with:
Fever and rigors.
Perception of body masses.
Any systemic abnormalities.
Disturbed conscious level.
The patient sought medical advice several times and was told that it is an attack of gastroenteritis.
Several antiemetics, antispasmotics and antibiotics were taken with no remarkable improvement.
PAST HISTORY
History of surgical operations:
Hysterectomy 5years ago.
History of blood transfusion ( 2units of blood prior to hysterectomy ).
No history of diabetes or hypertension.
No history of drug intake.
FAMILY HISTORY
No similar condition
Negative consanguinity
Summary
Persistent vomiting.
Periumbilical colicky pain.
Mild weight loss and anorexia.
D.D. of persistent vomiting:
GIT :
- Inflammation: Peptic ulceration, biliary colic.
- Obstruction: pyloric stenosis, malignancy.
- Infections: parasites, bacteria.
- Adhesions: surgical, T.B.
- Drugs: NSAIDs, alcohol, iron, antibiotics.
D.D. (continue):
CNS : Drugs e.g. narcotic analgesics, raised intracranial tension.
Ear : Labyrinthine disorders, M énie re ’ s disease.
Metabolic : Uraemia, Hypercalcaemia, D.K.A.
Endocrine : Addison ’ s disease.
Pregnancy .
Psychological .
ON ADMISSION
The patient was drowsy, dehydrated
Blood pressure 100/60
Pulse: 120/min , with occasional irregular beats
Random blood sugar: 100
Serum K: 3.9
ECG: ventricular extrasystoles
The patient was resuscitated with IV fluids, K supplements and antiemetics, followed by improvement of her general condition (blood pressure 120/80, pulse 80/min with no arrythmia , serum K 4.5, follow up ECG normal).
HEAD AND NECK
No pallor
No jaundice
No cyanosis
No palpable lymph nodes
Trachea central
Thyroid gland not felt
Neck veins are not congested
No signs of vitamins deficiency.
UPPER LIMBS
No pallor
No clubbing
No cyanosis
LOWER LIMBS
No oedema
ABDOMINAL EXAMINATION
Normal shape and contour
Subcostal angle: not widened.
No divarication of recti
Umbilicus: normal shape and position
No dilated veins or pigmentation
No hernias
Scar of previous hysterectomy ( transverse suprapubic ), healed by 1ry intention.
Superficial palpation:
no tenderness, no rigidity, no masses.
LIVER :
- Upper border : 5th space mid clavicular line.
- lower border:
Rt lobe in the MCL: not felt.
Lt lobe in the midline: 3cm sby lightpercussion .
SPLEEN : not felt.
ASCITES : not detected clinically.
CVS, CHEST & NEUROLOGICAL EXAMINATION
FREE
FUNDUS & SLIT LAMP EXAMINATION
FREE
INvestigations
STOOL ANALYSES :
( DONE FOR SUSCESSIVE 3 DAYS )
Physical properties:
Colour: brown
Odour: offensive
Consistency: formed
Blood: no
Mucus: no
Worms : no
Microscopic examination
Pus cells: few
RBCs: no
Fat cells: some
Vegetable cells: some
Parasitic ova: no
Protozoal vegetative: no
Protozoal cysts: no
CBC:
WBCs
Total: 11.500
B= 1
E= 60
St= 1
Seg= 9
Lymph= 26
Mon= 3
MARKED EOSINOPHILIA (6900 c)
Mild leucocytosis.
CAUSES OF MARKED EOSINOPHILIA:
C : Connective tissue disease ( Churg-Strauss vasculitis, Rheumatoid arthritis, Eosinophilic fasciitis ).
H : Helmintic diseases ( Ascariasis, Schistosomiasis, Visceral larva migrans, Strongyloidiasis, Fascioliasis, Paragonimiasis ).
I : Idiopathic, Inflammatory ( eosinophilic gastroenteritis ).
N : Neoplastic ( Lymphoma, Eosinophilic leukemia, Gastric or lung carcinoma i.e. paraneoplastic eosinophilia ).
A : Allergy ( Asthma, Allergic rhinitis ).
LIVER BIOCHEMICAL PROFILE
BIL-T : 0.76
AST : 22
ALT : 29
ALP : 72
LDH : 221
ALBUMIN : 4.1
TOTAL PROTEIN : 7.3
PC: 90%
Creatinine: 0.75
Urea: 28
Na: 139
K: 4.3
ABDOMINAL ULTRASONOGRAPHY
LIVER: average in size, homogenous texture, smooth surface and normal hepatic veins. No focal lesions or IHBR dilatation. PV is not dilated.Mild portal tract thickening.
GALL BLADDER: average size and wall thickness, no stones or mud seen inside. CBD is not dilated.
SPLEEN : average size (longest axis 10.5cm) , homogenous echopattern.
KIDNEYS : both are of average size, and parenchymal echogenicity, no typical calculi or back pressure changes.
PANCREAS & midline structures are free.
NO ASCITES.
CONCLUSION: Mild portal tract thickening.
UPPER ENDOSCOPY
OESOPHAGUS: Normal
STOMACH: The mucosa of the antrum, body and the fundus is free
PYLORIC RING: Rounded and regular
DUODENUM: free up to the second part
CONCLUSION: Normal upper endoscopic findings
Multiple biopsies were taken from the duodenum, antrum and jejunum with duodenal aspirate.
DUODENAL ASPIRATE
NEGATIVE
BIOPSIES
OESOPHAGUS : Hyperplastic stratified squamous epithelium. The subepithelial tissue is
moderately infiltrated by eosinophils and contains congested capillaries.
JEJUNUM : The villi and the glands are within normal. The lamina propria is oedematous and infiltrated by chronic inflammatory cells with moderate numbers of eosinophils. The muscularis mucosa shows hypertrophy and focally infiltrated by eosinophils.
ANTRUM : Same pathological changes as jejunum.
CONCLUSION:
OESOPHAGEAL, ANTRAL AND JEJUNAL BIOPSIES
PICTURE TO BE CORRELATED TO THE CLINICAL PRESENTATION IS COMPATIBLE WITH
EOSINOPHILIC GASTROENTEROPATHY
BEFORE DIAGNOSING OUR CASE AS EOSINOPHILIC
GASTROENTERITIS OTHER CAUSES OF
EOSINOPHILIA SHOULD FIRST BE EXCLUDED
Connective tissue diseases:
No symptoms suggestive for arthralgia or vasculitis.
Autoimmune profile: -ve.
Helmentic diseases:
Stool and urine analysis: -ve
Duodenal aspirate: -ve
Serology for Fasciola : 1/80
Schistosoma serology 1/80, rectal snip – ve.
Neoplasm
No detectable lymph nodes.
CBC: no anemia, no thrombocytopenia.
No immature eosinophils in the CBC and bone marrow aspirate and biopsy.
Bone marrow examination has no blast forms.
Allergy
No known allergy to certain foods.
No history of drug intake.
Hypereosinophilic syndrome
Absence of eosinophil blast cells in the marrow or blood, But..
Eosinophilia is less than 6 months.
No multiorgan involvement (Echo heart, chest x- ray no abnormalities detected).
Eosinophilic gastroenteritis!!
The presence of abnormal GI symptoms.
Eosinophilic infiltration in 1 or more areas of the GI tract, defined as 20 or more eosinophils per high-power field.
The absence of an identified cause of eosinophilia.
The exclusion of eosinophilic involvement in organs other than the gut.
Thank you
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