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Author: Laura E Divoky, MD, Northeast Ohio
Medical University, Class of 2011, Summa Health System, PGY-1
Introduction: Hypereosinophilic syndrome (HES)
is a heterogeneous group of conditions characterized by blood
eosinophilia and end-organ dysfunction from eosinophilic
infiltration and activation, thrombotic events and toxic mediator
release.1-3 End-organ damage commonly affects the skin,
heart, lungs, gastrointestinal tract, joints, and nervous system.
Idiopathic HES is defined by persistent elevation of blood
eosinophil count greater than 1500/µL for six consecutive
months, of an unknown cause, and evidence of underlying end-organ
Case Report: A 50-year-old Caucasian female
with multiple food sensitivities and atopy presents with chronic
dysphagia, abdominal cramping and watery diarrhea. Her medication
and travel history were unremarkable. Lab values were notable for
persistently elevated eosinophil count of 1,909 cells/µL,
elevated IgE levels of 479 IU/mL (normal 0.0-100.0) and elevated
Strongyloides stecoralis IgG titers of 7.65 IV (normal < 2.11).
Upper endoscopy with biopsies was performed and histopathologic
exam revealed florid eosinophilic inflammation with eosinophilic
cryptitis pervading the esophagus and stomach. Duodenal biopsies
were negative for ova and parasitic infiltration. Despite
Ivermectin therapy, the Strongyloides titers remained elevated,
with eosinophil count increased to 2,503 cells/µL. It was
concluded that the elevated titers represented a false positive and
parasitic infection was excluded as a source for her eosinophilia.
Bone marrow biopsy revealed no evidence of a clonal T- or B-cell
population on immunophenotyping, and FIP1L1-PDGFRA gene
fusion was not detected.
Discussion: This case represents a unique
diagnostic challenge because no apparent cause for the eosinophilia
with gastrointestinal involvement could be identified, despite an
extensive workup that ruled out clonal and reactive eosinophilia
(i.e. infections, allergies, respiratory diseases, vasculitides,
mixed connective tissue disease, medications, and non-hematological
malignancies). Despite strict allergen avoidance, eosinophilia did
not resolve. Despite the unique presentation, we surmise that this
patient meets the criteria for IHES and warrants close monitoring
with prompt treatment with prednisone or interferon-alfa to
minimize end-organ damage from eosinophilia.
March 2012 Issue of IMpact