The identification of eosinophilic gastroenteritis in prednisone-dependent eosinophilic bronchitis and asthma
© Nair et al; licensee BioMed Central Ltd. 2011
Received: 9 January 2011
Accepted: 1 March 2011
Published: 1 March 2011
This case reports the unique association of eosinophilic gastrointestinal disease with eosinophilic bronchitis, asthma and chronic rhinosinusitis and some features of lymphocytic hypereosinophilic syndrome, describes a diagnostic protocol for patients with asthma and persistent eosinophilic bronchitis, and suggests that the use of a novel EPX-mAb provides a reliable method to identify eosinophilic inflammation.
Eosinophilic gastrointestinal disease (EGID) is characterized by identification of abnormal eosinophilic infiltration on morphologic evaluation of gastrointestinal tissues obtained by biopsy or resection from patients with gastrointestinal complaints . EGIDs are classified according to the site involved (i.e., esophageal, gastric, small intestinal, colonic, or multiple). Esophagus is increasingly being recognized as a site of involvement with eosinophils accumulating in the mucosal, muscular, serosal, diffuse, or transmural areas . The diagnosis for eosinophilic esophagitis and other EGIDs is established after ruling out other causes of an eosinophilic disease, particularly atopy, parasitic infestations, vasculitis, and hypereosinophilic syndrome (HES) . We report the association of eosinophilic gastroenteritis and eosinophilic bronchitis in a young patient with prednisone-dependent asthma and some features of lymphocytic hypereosinophilic syndrome and the sensitivity of a novel monoclonal antibody directed against eosinophil peroxidase (EPX-mAb)  as an unambiguous means with which to detect both infiltrating tissue eosinophils and eosinophil degranulation in gastrointestinal tract biopsies. The patient provided written informed consent for publishing this manuscript.
Investigations for persistent airway eosinophilia
Blood eosinophil (×109/L)
Total serum IgE (IU/L)
ANA, c-, p-ANCA
Aspergillus, farm, bird precipitins
Serum B12, pg/ml
Serum LDH, IU/L
Serum tryptase, IU/L
Serum TARC, pg/ml
Sputum IL-5, pg/ml
Stool for parasites (×3)
Toxocaris, Strongyloides serology
Pan sinusitis, polyps
Minimal airspace, no nodes
No clonal abnormalities
PDGFR-FIP1L1, c-kit, abl-bcr
Mild global hypokinesia
Normal, mitral valve prolpase
Eosinophils, no vasculitis
Normal, no vasculitis
Eosinophils, no vasculitis
BAL eosinophils 6%
This clinical case provides an example of a unique association of eosinophilic gastroenteritis with eosinophilic bronchitis and asthma in the absence of atopy, vasculitis or classical hypereosinophilic syndrome. Our observations with this patient also highlight the utility of a new eosinophil-specific monoclonal antibody as a diagnostic maker of eosinophil-associated disease states.
The three clinical syndromes that may present with symptoms similar to this patient are vasculitis, chronic eosinophilic pneumonia and hypereosinophilic syndrome. Anti-neutrophil antibodies were repeatedly negative and intestinal, sinus and bronchial mucosal tissues did not show evidence of vasculitis. Although the initial radiological feature may have been consistent with chronic eosinophilic pneumonia, subsequent clinical history and radiology were not consistent with this diagnosis. Traditionally, the diagnosis is not entertained in patients who have asthma or chronic rhinosinusitis.. However, it is increasingly recognized that there is considerable overlap between the clinical and molecular patterns observed in patients with eosinophil-mediated diseases . The patient did not have the classic clinical or laboratory features of myeloproliferation. Further, the mutation-related gain-of-function kinase specifically involved in the pathogenesis of myeloproliferative HES (eg, FIP1L1/PDGFRA) was not detected. However, the patient had raised levels of the eosinophilopoietic cytokine IL-5 in sputum (R&D, Mississauga, ON) and the T-cell derived eosinophilopoietin, TARC, in serum (Calbiochem, Mississauga, ON). However, we were unable to demonstrate T-cell populations in peripheral blood characterized by TCRα/β-CD3-CD4+ or CD3+CD4-CD8- that are described in patients with lymphocytic forms of HES . Bone marrow examination did not show any clonal expansion of lymphocytes or eosinophils. Overall, we believe that the patient may have had a variant of a lymphocytic hypereosinophilic syndrome given the systemic eosinophilia, modestly high levels of sputum IL-5 and serum TARC and raised serum total IgE early in the course of the disease. It is possible that an unidentified allergen triggered eosinophil expansion in the bone marrow through an IgE-mediated or a non-IgE-mediated, direct T-cell interaction.
The second novel aspect of this case report is the use of a novel monoclonal antibody to identify eosinophilic infiltration of the gut. The robust character of this novel antibody (specificity and sensitivity)  proved invaluable to the establishment of an appropriate diagnosis by detecting both infiltrating eosinophils and the presence of eosinophil degranulation when conventional eosin and hematoxylin staining of the tissue was not interpreted as being significant by two independent pathologists. The other eosinophil granules such as ECP  and EDN  are not specific to eosinophils, being present on neutrophils. The cationic character of MBP, together with its propensity to "stick" to virtually any substratum as well as its near insolubility in environments at neutral pH limits its utility for immunohistochemistry . Moreover, these intensely staining local aggregates may give the perception of eosinophil degranulation. In contrast, the nominal cationic character of EPX together with its greater solubility at neutral pH would prevent aggregation and allow this granule protein to disperse to a greater extent.
The third objective of this case report is to describe our protocol to evaluate patients with asthma who have persistent airway eosinophilia identified as sputum eosinophils >3% on two or more occasions (table 1). The investigations include workup for atopy, vasculitis, allergic bronchopulmonary aspergillosis, chronic eosinophilic pneumonia and HES. In addition, we also evaluate for hyperplastic chronic rhinosinusitis and non-IgE mediated eosinophilia possibly mediated by antigen-triggered IL-5 release from T-lymphocytes. We also recommend an assessment of steroid pharmacokinetics to monitor compliance and gastrointestinal absorption of ingested corticosteroids.
In summary, this case describes a patient who likely has a lymphocytic variant of hypereosinophilic syndrome that resulted in eosinophilic infiltration of the gastrointestinal tract, sinuses, and airway that contributed to variable airflow obstruction. The case history also illustrates the diagnostic workup of a patient with asthma who has a prednisone-dependent airway eosinophilia. The use of a novel EPX-mAb provided a reliable method to identify eosinophils in the gastrointestinal tract. Further research is necessary to identify the triggers for eosinophilia in L-HES and the application of the novel monoclonal antibody directed against eosinophil peroxidase to detect eosinophil activity in the airway.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We acknowledge the help of Dr Mike Trus, Dr Susan Waserman, Dr Nader Khalidi, Dr Robert Spaziani and Dr Mark Larche in the management of this patient. Dr Nair is supported by a Canada Research Chair in Airway Inflammometry, Drs. N Lee and J Lee are supported by grants from the NIH (NAL: HL058732 and JJL: HL065228, RR019709)
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