Eosinophilic ascites: A diagnostic and therapeutic challenge
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Eosinophilic gastroenteritis (EGE) is a rare condition characterized by eosinophilic infiltration of the gastrointestinal tract. Depending on the dominant layer of infiltration it is classified into three types namely, mucosal, muscularis and subserosal. The most uncommon variant is the subserosal type characterized by primarily subserosal disease, eosinophilic ascites and peripheral hypereosinophilia. The clinical features are non-specific with history of atopic predisposition and allergy. Endoscopic biopsy is frequently non-diagnostic due to an uninvolved gastrointestinal mucosa rendering its diagnosis a challenge. The mainstay of diagnosis is peripheral hypereosinophilia and eosinophil-rich ascitic fluid on diagnostic paracentesis. Oral steroid therapy is usually the first line of treatment with dramatic response. Due to a propensity for relapse, steroid-sparing therapy should be considered for relapses of EGE. We report a case of subserosal EGE with diagnostic clinical features and treatment response and review the current strategy in the management of eosinophilic ascites.

A 35-year-old female presented to the clinic with complaints of abdominal distension and an episode of self-limiting diarrhea three weeks ago. She admitted to the recent use of green tea and increased consumption of nuts in her diet. Past medical history was remarkable for recurrent allergic bronchitis. On examination there was no evidence of pallor, icterus or peripheral edema and abdominal examination revealed moderate distention with a doughy consistency. Abdominal ultrasonography demonstrated moderate ascites with no signs of portal hypertension, liver or renal disease. Contrast-enhanced abdominal computed tomography confirmed the presence of free peritoneal fluid, diffuse circumferential thickening of small bowel loops, distal stomach and esophagus (Figure ?(Figure1).1). Laboratory examination revealed peripheral eosinophilic leukocytosis with 52% eosinophils (total leukocyte count 22900 cells/mm3) and no immature myeloid precursors. The C-reactive protein, erythrocyte sedimentation rate and IgE levels were within normal limits....