Question of the Week # 379 & 380

379)  A 38  year old man from India presents to out-patient clinic with complaints of abdominal pain and bloating. He also reports having intermittent diarrhea. His symptoms are worse upon eating and have progressively worsened over the past 6 months. He has lost about 6 lbs weight over the same period. He has come to visit his sister in the United States and she forced him to seek medical attention. Upon review of systems, he reports intermittent cough associated with mild shortness of breath and wheezing. His past medical history includes frequent episodes of sinus infections. On examination, he appears comfortable. Chest, Cardiac and Abdominal examination is benign. Chest X-ray is normal. Laboratory investigations are shown below:

WBC : 9.0k/µl

Differential : Neutophils 42%, Lymphocytes 30%, Monocytes 8%, Eosinophils 18%

Hemoglobin 13.5gm%

Platelet count 280k/µl

HIV serology : Negative

Stool for ova and parasites : Negative

Liver function Tests: Normal

Serum Creatinine : 1.0mg%

Urinalysis : normal

Which of the following  is the most likely diagnosis?

A) Chagas Disease

B) Eosinophilic Gastroenteritis

C) Churg Strauss Syndrome

D) Wegener’s Granulomatosis

E) Tropical Pulmonary Eosinophilia ( Microfilariasis)

380) Which of the following is the most appropriate next step?

A) Upper GI Endoscopy

B) Pulmonary Function Tests

C) Trypanosoma Cruzi Antibodies

D) Di-ethyl carbazine therapy

E) Anti-Proteinase -3 antibodies ( C-ANCA)

7 Responses

  1. B) Eosinophilic Gastroenteritis Vs C) Churg Strauss Syndrome
    Prefer Churg Strauss Syndrome because intermittent cough associated with mild shortness of breath and wheezing and past history of frequent episodes of sinus infection. For intermittent diarrhoea, if pt has eosinophilia, eosinophils penetrate the GI mucosa and can cause diarrhoea.

  2. D. E.

  3. B) Eosinophilic Gastroenteritis – the only one that can explain both GI and pulmonary sx
    also clues like symptoms worsening upon eating also point to it

    A) Upper GI Endoscopy

  4. e and d……..

  5. admin, please answer this question

    • Answer C & A . ( sinopulmonary disease, diarrhea, wheezing etc associated with peripheral blood eosinophilia is characteristic of Chug strauss) . Chug strausss is a clinical diagnosis . ACR criteria for churg strauss include : presence of 4 or more of following six criteria
      a) Peripheral blood eosinophilia > 10%
      b) Neuropathy : Mononeuropathy or mononeuritis multiplex or polyneuropathy
      c) Radiographic presence of migratory or transient pulmonary opacities
      d) Abnormalities of Paranasal sinuses
      e) Biopsy of any involved organ showing a blood vessel with extravascular eosinophilic accumulation
      f) Asthma (hx of SOB, Wheezing or presence of rhonchi, wheezes on examination)
      The patient in the question satisfies three criteria from the above list ( a,c, d). He does have GI tract involvement and therefore, doing an EGD will help establish the diagnosis and also to exclude other differential diagnosis. The EGD is most likely to show eosinophilic gastroenteritis in this patient. However, the patient has other features of extra- intestinal involvement – characterizing a syndrome (multi-organ involvement) rather than simple eosinophilic gastroenteritis. His picture therefore, fits the diagnosis of Churg-Strauss SYNDROME!

      India is just a distractor – patients with wuchereria can have tropical eosinophilic pneumonia but wuchereria does not produce GI tract symptoms. Peripheral eosinophia is profound.

      Chagas disease seen in south America may present with esophageal involvement and other features such as cardiomyopathy.

      Gastroenteritis and pulmonary involvement do not occur. Peripheral eosinophilia does not occur in chagas.

      Wegener’s is a pulmonary –renal syndrome. It often involves upper respiratory tract ( recurrent sinus infections), lungs and kidney causing sinusitis, pulmonary hemorrhages and glomerulonephritis. It does not involve GI tract. It does not present with eosinophilia as well.

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