Eosinophilic Gastroenteritis Presenting as Hypoalbuminemia

Introduction: Eosinophilic gastritis and gastroenteritis (EG/EGE) are inflammatory disorders characterized by eosinophilic infiltration of the stomach and/or duodenum, rarely also impacting the distal small bowel and colon. Case Description/Methods: We present a challenging case of eosinophilic gastroenteritis in a 64-year-old male with history of IgG Kappa monoclonal smoldering multiple myeloma who developed hypoalbunemia and lower and upper extremity edema. He was referred for concern for protein losing enteropathy. Lab work up was significant for an albumin level of 2.6 g/dl, and peripheral eosinophils were elevated to 9.5 %. Workup showed no cardiac etiology or deep venous thrombosis. Urine analysis was negative for protein loss. Computed tomography abdomen pelvis was normal. Infectious workup including stool testing for ova and parasites, HIV screening, and strongyloides IgG were negative. Stool tryptase was negative. Endoscopy was notable for impressively enlarged gastric folds with diffuse, patchy erythema (Fig. 1 right side). Mucosa was otherwise unremarkable on upper and lower endoscopy. Pathology of gastric biopsies showed >30 eosinophils per high-power field in the lamina propria, and biopsies of the ileum and colon were also notable for an increased eosinophilic infiltrate (Fig.1 left side). The patient was started on oral prednisone 40 mg daily, with improvement in peripheral eosinophil counts and albumin, though lab values were suggestive of recurrence with completion of steroid taper. The patient is currently planned for additional workup including bone marrow biopsy, as well as referral to a dietician for food elimination diet trial and allergist for environmental allergy evaluation. Discussion: The natural history and disease course of EG/EGE is not well defined. Dietary therapy and treatment with prednisone have been described as possible interventions, largely extrapolated from studies on eosinophilic esophagitis. Patients are often followed for response to treatments based upon their symptoms and the changes in peripheral eosinophilia. Other therapies like anti-Immunoglobulin E (IgE) monoclonal antibody, Leukotriene antagonist, H1-antihistamine and mast cell stabilizer and anti-Siglec-8 antibody that depletes eosinophils and inhibits mast cells, have bSeen looked into some case series but not routinely used.Figure 1.: Endoscopy with Narrow Band Imaging: (a) gastric body, (b) pre-pyloric stomach. Surgical pathology: (c) Active gastritis. Insert: H pylori (arrows), (d) Single focus of signet-ring adenocarcinoma (arrows).