PMC425596_01
PMC425596_02
Esophagogastroduodenoscopy showing gastric erosion (A) and esophogitis (B). Panels C and D show eosinophil infiltration of gastric biopsy samples.
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F1
Images revealed multiple erosions in the gastric and duodenal mucosa and Barrett's esophagitis (Figure 1A and 1B). Gastric biopsy showed eosinophilic infiltration of the mucosa in clusters, a diagnostic feature of eosinophilic gastritis (Figure 1C and 1D).
Pathology of eosinophilic gastritis. In the presence of an inciting event, inflammatory cells like T-cells and mast cells are activated to produce a host of eosinophilic cytokines that regulate eosinophil biology, activation, recruitment, and survival. Once in the gastric mucosa, eosinophils can orchestrate tissue damage by releasing toxic proteins like eosinophil cationic protein, major basic protein, eosinophil peroxidase, and eosinophil derived neurotoxin. With mucosal injury, vomiting, diarrhea, cachexia, and peripheral edema ensue.
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F2
The peripheral edema was most likely secondary to the protein losing enteropathy, hypoalbuminemia, and cachexia (Figure 2). Figure 2 demonstrates presumed pathways that could lead to the development of eosinophilic gastritis.
PMC425596_03
Remission of Nausea and Vomiting with Prednisone. One cycle shown. Nausea was graded by patient from 0 (absent) to 10 (constant/severe). "P" indicates where prednisone was initiated. Prednisone dose is provided in mg/day in parenthesis on x-axis. After prednisone was initiated and maintained at 10-20 mg/day, the patients cyclical vomiting was aborted for the next 2 years of follow up. Body weight, total protein, and albumin levels improved, while eosinophilia was absent.
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F3
The cyclical vomiting episodes were aborted (one such cycle is shown in Figure 3.