A 17-year-old girl was admitted to the local gynaecology unit with recurrent abdominal cramps, nausea and vomiting. She had a history of repeated episodes of abdominal pain in the past. The symptoms had begun some years earlier, causing several hospitalizations and two laparoscopic interventions.
Medical history revealed allergic coryza and neurodermatitis, but no food allergy. No other diseases were reported.
Laboratory rendered a high white blood cell count (WBC) 13.300 x 109/liter with an eosinophil count of 58% and CRP 5.2 mg/l. Laparoscopy showed a large amount of ascites and swollen intraabdominal lymph nodes. Thus, screening for tuberculosis was initiated. A chest x-ray showed no signs of pulmonary disease, Mantoux test and all cultures remained negative. However, one pcr from ascites was positive and the diagnosis of intestinal tuberculosis was established. The patient was started on rifampicin, isoniazid, ethambutol and pyrazinamide. Despite treatment symptoms persisted for the following six month.
On admission the patient was still under therapy with rifampicin and isoniazid. Physical examination demonstrated diffuse abdominal tenderness without peritoneal signs. The WBC was 13100 x 109/liter with an eosinophilic count of 53 %, total IgE 1870 kU/l and CRP 32 mg/l. Clinical and laboratory indices for autoimmune disease were absent. Abdominal ultrasound and computed tomography showed ubiquitous ascites and thickening of the wall of the lower oesophagus, stomach and bowel (Fig. 1). The patient developed severe abdominal pain, only controlled by opoid analgesia. An iliac crest biopsy showed an eosinophilic count over 40 percent but no signs of leukaemia. Again the ascitic fluid rendered a high eosinophilic count. Blood tests as well as stool cultures and microscopy for ova and parasites were negative. Endoscopy of the upper intestinum and the colon showed no abnormalities of the intestinal mucosa. Remarkably biopsies from oesophagus, stomach, ileum and colon yielded distinct eosinophilic infiltrations reaching the lamina propria which finally lead to the diagnosis of a primary eosinophilic gastrointestinal disorder (Fig. 2).
Thus, this patient fulfilled all diagnostic criteria for eosinophilic gastroenteritis. Since active tuberculosis was ruled out we stopped anti-mycobacterial treatment.
The patient was switched to 40 mg prednisone per day. Symptoms were alleviated quickly in the beginning. The patient was set on a taper. Reaching a dose of 10 mg a day symptoms started again. Therefore the dose was doubled and Montelukast 10 mg/d was started. The symptoms resolved within days and the prednisone could be tapered within six weeks. Currently, the patient remains completely off steroids. She has been symptom free for the last 24 months under Montelukast. Regular physical examinations and blood tests have shown normal results.