A 57-year-old Indian male with HIV-positive status was admitted to our hospital with chief complaints of large-volume watery stools without blood or mucus, 3-4 times a day for 4 months with recent exacerbation for 1 week. This was also associated with nausea, loss of appetite, significant weight loss, generalized weakness, and dysphagia to solids. He denied personal or family history of allergies. He was diagnosed with HIV infection 17 years ago and was on treatment with antiretroviral drugs, namely raltegravir, lamivudine, and efavirenz. He was also diagnosed with pulmonary tuberculosis 5 months back for which he was on treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol. He unintentionally lost 20 kg of weight over the past 4 months. He further denied the use of laxatives or any complementary or alternative medications. He had stable vital signs, was cachectic, and had a normal systemic examination. His workup for chronic diarrhea included a normal thyroid function test and no opportunistic infections or helminthic infestation. Stool analysis including culture was negative for Clostridium difficile toxin, Cryptosporidium, Vibrio cholerae, acid-fast bacteria, or any other parasites. Serum IgE concentration was also within the normal range. Other investigations revealed hemoglobin 11.4 g/dL (13-18 g/dL), platelets 244,000/uL (140,000-440,000/uL), and total leukocyte count 4880/mm3 (4000-10000/mm3) with neutrophils 78.5% (40%-75%), lymphocytes 16.2% (20%-45%), and eosinophils 0.8% (1%-6%). His total protein was 5.4 g/dL (6.60-8.70 g/dL), albumin 1.8 g/dL (3.97-4.94 g/dL), absolute CD4 count 89.91/mm3 of blood (400-1600/mm3 of blood), absolute CD8 count 427.68/mm3 of blood (280-1400/mm3 of blood), CD4 (helper T-cells)% 11.1% (28-58%), CD8 (suppressor T-cells)% 52.8% (19-49%), CD4/CD8 0.21 (1.2-3.3), and HIV-1 viral load by TaqMan plasma (quantitative) 12,59,309 copies/mL.
On further investigations, esophagogastro duodenoscopy revealed white mucosal plaques in the esophagus consistent with esophageal candidiasis. The mucosa of the duodenum showed focal erosions with blunting of the villi as seen in Figure 1. Urease test was negative for Helicobacter pylori. Mucosal biopsies from the stomach and duodenum were taken. Histopathology study shown in Figure 2 revealed active inflammation in the gastric and duodenal mucosa with excess eosinophils (20 eosinophils/high-power field) and no microorganisms. This was consistent with EGE. He also had a colonoscopy which was normal. Rifampicin was stopped during this admission for a period of 2 weeks. However, the persistence of diarrhea ruled out drug-induced EGE. He was then started on oral prednisolone 40 mg once daily. The frequency of stools decreased and consistency improved. Prednisolone was gradually tapered over a period of 2 months. This was associated with an increase in the frequency of watery stools like before resulting in a readmission with dehydration and weight loss.
The patient was restarted on oral prednisolone 60 mg once daily. Along with cessation of diarrhea, his appetite and weight improved during follow-up after 30 days. On 6-month follow-up, he has regained 18 kg and has normal stools. He is currently on oral prednisolone 40 mg once daily.