Acute eosinophilic ascites in a middle-aged man

Abstract

Eosinophilic gastroenteritis is a rare condition characterized by recurrent eosinophilic infiltration of portions of the GI tract and presenting with nonspecific GI symptoms in association with peripheral eosinophilia. Its etiology and pathogenesis remain unclear and its symptoms overlap with many GI and systemic diseases. Thus, both gastroenterologists and general internists need to be aware of this rare condition. We present a case of a 55-year-old male with diffuse abdominal pain and distention for two weeks. His physical examination was significant for moderate ascites. Initial work-up demonstrated severe peripheral blood eosinophilia, normal liver function tests, thickening of the stomach and small bowel wall, and elevated serum IgE. Upper endoscopy and extensive testing for malignancy and parasitic infections failed to establish a diagnosis. Ascitic fluid analysis showed significant eosinophilia. Further, a full-thickness jejunal showed marked eosinophilic infiltration of the serosa and muscularis propria. Subsequent treatment with oral prednisone resulted in normalization of laboratory and radiologic abnormalities in a few week period.

Figure 1

This computer tomography image of the abdomen and pelvis with oral and intravenous contrast shows multiple areas of small bowel wall thickening (arrowheads). Also notice the perihepatic accumulation of ascitic fluid (arrow).

Figure 2

This high-power oil immersion view of the peripheral blood shows two eosinophils. In addition, a lymphocyte is present as well as abundant background of red blood cells (Wright-Giemsa stain; magnification 1000×).

Figure 3

This high-power oil immersion view of ascitic fluid shows two degenerating eosinophils containing eosinophilic granules and bilobed nuclei (H&E stain; magnification 1000×).

Figure 4

Laparoscopic evaluation of the patient revealed skipped areas of serosal inflammation involving the small bowel and to a lesser degree the colon. This view of the biopsied part of jejunum reveals an area of hyperemia and dilated blood vessels indicating an inflammatory process (arrowheads).

Figure 5

This high-power oil immersion view of the serosa shows sheets of eosinophils with abundant eosinophilic granules (H&E stain; magnification 1000×).