Chronic Abdominal Pain and Eosinophilia

Abstract

A 9~YEAR~OLD child was seen with peripheral 9-YEAR.-C~LD child was seen with peripheral eosinophilia and the insidious onset of chronic, severe abdominal pain accompanied by features of malabsorption and marked weight loss. His evaluation demonstrates the difficulty in distinguishing strongyloidiasis from inflammatory bowel disease and eosinophilic gastroenteritis. Case Report A 9-year-old Caucasian male was seen in November of 1979 with intense, cramping abdominal pain of 24 hours' duration. His physical examination was essentially normal except for some mild voluntary abdominal guarding in the right upper quadrant. Weight was 92 pounds (90%) and height 54.5 inches (50%). Past medical history was significant only for hayfever and atopic disease. Laboratory findings: WBC 7,400/cu mm with 50% polymorphonudeocytes, 38% lymphocytes, 5% monocytes, 6% eosinophils, and I Elo basophils; hemoglobin 14.0 g/dl; hematocrit 39.9Elo;' sedimentation rate (Wintrobe) 8 mm/hr; heterophile negative; and SGOT 21 UJL. This episode spontaneously resolved over the next . few days without a specific diagnosis.About a year later, the patient returned to the office for recurrent episodes of intense, gnawing, mid-epigastric pain accompanied by occasional vomiting over a period of nine weeks; the episodes would occur at any time of the day, without relation to meals, and might last up to two or three hours. Physical examination at this time was remarkable for a 12-pound weight loss. He had guiac-positive stools and also passed some grossly bloody stools.Laboratory: WBC 9,400/cu mm with 36% neutrophils, 29% lymphocytes, 3% monocytes, and 32% eosinophils; hemoglobin 15.3 g/dl; hematocrit 43%; peripheral smear within normal limits; absolute eosinophils count 2834/cu mm; sedimentation rate 7 mm/hr; CRP negative; total protein 6.6 g/d1; albumin 4.3 g/dl; serum immunoelectrophoresis, nor-_ mal; IgE 280 U f ml; rheumatoid factor negative; bilirubin 0.4 mg/dl; SGPT I 1U/!; SGOT 9 IU/l; amylase 127 dye units/dl; serum folate 4.6 ng/ml; carotene 42 mcg/dI. Serum samples sent to the Center for Disease Control (CDC) for ascaris, toxocara (ELISA), and cysticercosis titers (IHA) were negative. Stool samples for ova and parasites were negative on three separate occasions. Meckel's scan was negative. Barium enema showed minimal changes in the distal colon consistent with early nonspecific colitis.The patient was referred to the University of California, Davis, Medical Center, Department of Pediatric Gastroenterology for further evaluation. A physical examination was again recorded as normal except for the declining growth parameters. Upper gastrointestinal series with small-bowel follow-through was normal. Esophagogastroduodenoscopy was unrevealing; biopsy of the gastric mucosa was normal, but no tissue of duodenal origin was obtained. On colonoscopy, the sigmoid area and the first 3 cm of the descending colon appeared normal. Multiple biopsies were obtained. The lamina propria was edematous and, in some areas, showed an increase in fibrous tissue, which ...