Gastro Case Challenge: An Incarcerated 24-Year-Old With Dyspnea, Fatigue, and Chronic Nausea

Nicola E. Burch, MBChB, MRCP; Victoria M. Gordon, MBBS, MRCP


March 18, 2022

Once the diagnosis of idiopathic eosinophilic gastroenteritis has been confirmed, the mainstay of treatment is primarily oral glucocorticoids, such as prednisone, to halt the inflammatory process and control symptoms. Budesonide has also been used successfully as an alternative.

Some researchers have investigated the elimination of possible allergenic foci (eg, dietary components, including milk, eggs, wheat and/or gluten, soy, and beef), as well as the use of skin testing to identify allergens; however, the effectiveness of this has yet to be proven.[2,7] In addition, mast cell stabilizers and other immunosuppressants (eg, montelukast, ketotifen, suplatast tosilate, mycophenolate mofetil) have been used in some cases; however, the success of these therapies has varied. Herbal therapies and Chinese medicine have also been evaluated, but no definite benefit has been shown to date. Surgery may be necessary in treatment-resistant cases, but this is generally considered a last resort, unless it is necessary to relieve persistent pyloric or small-bowel obstruction.[2,3,7]

The aim of early diagnosis and treatment is to prevent long-term complications, such as refractory ascites, bowel obstruction, perforation, recurrent iron deficiency anemia, and (rarely) premature death.[2]

In view of the histologic findings, the patient in this case was prescribed budesonide (9 mg daily). After the first month, the dose was reduced to 6 mg, and then to 3 mg for the third and final month. After budesonide was initiated, the eosinophilia apparently dropped.

After completion of a course of reduced-dose budesonide over 3 months, the patient remained well, and on laboratory examination had an eosinophil count at the higher end of the normal range. He did not require any further admissions for management of his symptomatic anemia and did not experience any other known complications. He was followed on a quarterly basis. A plan for the reinstatement of budesonide treatment should the patient develop additional complications was established.

This case highlights the diagnostic challenge of a condition that presents with common symptoms and apparently normal investigations. These findings should motivate and encourage the clinician to consider rarer diagnoses and pay special attention to seemingly unimportant clues, no matter how small, that may have been present all along. In this case, the patient had low-grade eosinophilia at the very first presentation, which was confirmed on review of previous examinations.


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