A 21-year-old woman of Cuban origin presented with multiple digestive complaints. Severe watery diarrhea and poor feeding tolerance were documented shortly after birth. During her childhood she adopted several dietary restrictions, avoiding gluten, lactose, and fruits with no significant improvement. At age 14 years, intermittent abdominal pain and refractory iron-deficiency anemia were noted. Her medications included oral and intravenous iron supplements. At age 20 years, esophagogastroduodenoscopy (EGD) showed diffuse severe inflammation with edema, erythema, and nodularity in the gastric body (Figure 1). Histopathology was positive for H. pylori and showed normal duodenal mucosa without villous atrophy. Serology was negative for celiac disease while on a diet containing gluten. Her autoimmune panel was unremarkable. H. pylori was successfully eradicated with triple therapy (clarithromycin, amoxicillin, and omeprazole), but severe cramping persisted.
At age 21 years, she was referred to our clinic, with disabling abdominal pain that worsened after food ingestion. Additional symptoms included low-grade fevers, acid reflux, persistent hiccups, and postprandial diarrhea. Physical exam revealed a slim patient (body mass index 19.5 kg/m2). Laboratory studies showed hemoglobin and hematocrit on the lower-normal range. Serum immunoglobulin G (IgG), IgM, IgA, IgE, C3, and C4 were normal. Stool studies were negative for ova and parasites.
A second EGD showed diffuse gastric atrophy and blotchy areas of erythema, with significant improvement from prior endoscopy (Figure 2). Prior gastric nodularity resolved, and both the esophagus and duodenum were normal. Histopathology revealed chronic gastritis with subepithelial collagen thickening that was confirmed with Masson trichrome stain. The collagenous band thickness measured 200 mum with a scattered infiltrate of plasma cells and eosinophils. H. pylori immunostaining was negative (Figure 3). Colonoscopy was normal, and random biopsies showed no evidence of collagenous colitis. Computed tomography enterography, a fructose intolerance test, and capsule endoscopy were unremarkable.
CG was diagnosed. The patient was started on oral budesonide, delayed-release capsules, at a dose of 3 mg twice a day. The capsules were opened and the granules mixed with maple syrup. Six months later, the patient showed moderate improvement of abdominal pain, anemia resolution, and persistent heartburn.