1. Eosinophilic gastroenteritis in Churg-Strauss syndrome
Daegu Catholic Medical Center
Dept. of Internal Medicine
Jin Tae Jung

2. Case (F/40) C/C: abdominal distension & generalized edema for 15 days
P/I: whole abdominal pain with gradually aggravating
abdominal distension, generalized edema &
diarrhea(#4-5/d) for 15days
PHx: DM (4-5 yrs ago Dx.: not under medication)
asthma (+, intermittently medication at LMC)
allergy (-)
FHx: unremarkable

3. Physical exam V/S: BP 144 / 90, PR 80, BT 36.8℃, RR 26
G/A: acute ill appearance, alert
Eye: anicteric sclera, not pale conjunctiva
Chest: regular HB without murmur
clear BS without rale
Abdomen: soft & distended
tenderness(+) with shifting dullness
Liver - firm, 2 FB palpable
Extremity: pitting edema (++/++)

4. Laboratory findings CBC: 28,500 / 11.3 / 60,000 (Eo 36.9%, 10,516/ul)
LFT: Tp/alb 9.1 / 2.4 g/dl AST/ALT 22 / 26 IU/l
TB 0.9 mg/dl ALP 341 IU/l
BUN/Cr: 30 / 2.3 mg/dl IgE 1000 IU/ml
Stool: OB (-), protozoa (-), RBC/ WBC (-)/(-)
Skin test for CS & PW (-)
Paracentesis: RBC 5-10,
WBC 1,300 (poly : 30%, Eo 3.7%)

5. Abd-pelvic CT diffuse intestinal wall edema
generalized edema & ascites
enlarged LNs in mesenteric
& paraaortic regions

6. Endoscopy
diffuse mucosal erythema
and edema,
whole stomach & duodenum

7. Colonoscopy multiple patchy erythema & mucosal edema
from terminal ileum to rectum

8. Biopsy extravascular eosinophil infiltration with
small vessel vasculitis – stomach, duodenum, terminal ileum, colon
Stomach
Terminal ileum
Ascending colon

9. Progress (I)
Final Dx.: eosinophilic gastroenteritis(mucosal type), NIDDM
→ steroid 50mg start with insulin : resolved symptom &
discharged on 10th hospital day.
2nd admission (2 months later, 청주성모병원)
- Dx.: acute MI → balloon PTCA at pLAD
- BM asp.: hypercellular marrow (cellularity 70%)
eosinophil (15.8%), no cluster of malignant cells.
3rd admission (2 months later, DCMC)
- C/C: abdominal pain & distension (1 month after steroid stop)
severe dyspnea attack on admission day
ABGA : / 37.8 / 59.4 / 23.4 / 91.1%
→ steroid 50mg restarted:
discharged after 7 days without symptom.

10. Progress (II) 4th admission (3 months later, DCMC)
- C/C: facial swelling, generalized edema & dyspnea
→ ER visit (15days after steroid discontinuation)
→ admitted to ICU after endotracheal intubation
- P/E: facial edema with conjunctival edema,
lip swelling, bronchial wheezing
- Consult Rheumatology under impression of
vasculitis or angioedema.

11. Laboratory findings(4th Adm.)
CBC: 19,700/9.8/64,000 (Eo 2.9%, 571/ul) IgE: 1000 IU/ml
ESR: 120 → 10 mm/hr CRP : → 12.4 mg/l
Tp/alb : 7.5/2.3 g/l, BUN/Cr : 28 / 2.1 mg/dl
ABGA : / 28 / 78.6 / 17.6 / 96%
Ig G/A/M : 3036 / 61 / 45 mg/dl lupus anticoagulant : (-)
RF : 12.9 IU/ml ASO : 33.2 IU/ml
ANA : 1:80, homogenous Anti ds-DNA : 1.62 IU/ml
ANCA (Anti MPO / PR-3 Ab : 55 / 53)
C3/C4 : <30 / <6 mg/dl CH50 : 4.0 U/ml
EMG : peripheral motor polyneuropathy in peroneal & tibial N.

12. Rt. maxillary & ethmoidal sinusitis
Chest PA
Facial CT
Rt. maxillary & ethmoidal sinusitis

13. Chest CT Abd-pelvic CT - multiple enlarged LNs
- pleural effusion, both
Abd-pelvic CT
- generalized edema
- scanty ascites
- paraaortic lymphadenopathy

14. Progress (III) Final Dx. : Churg-Strauss syndrome
→ high dose steroid pulse therapy (1g/d for 3 days)
→ resolved her symptoms of angioedema & dyspnea
→ discharged after 12 days without symptom.
OPD follow up
with tapering of steroid (2 months later)
→ weakness of Lt. forearm developed
→ brain CT : acute brain infarction
→ pt refused admission because of low economic status
→ warfarin started
& slight improvement in weakness

15. low density in Rt Frontoparietal region
Brain CT
low density in Rt Frontoparietal region