Pancreatitis, Hepatitis And Gastritis With Eosinophilia: Case Report And Literature Review

OBJECTIVE:To present a case report of a patient with pancreatitis,hepatitis and gastritis with eosinophilia and perform literature review.Eosinophilia with involvement of multiple organs is a rare clinical event.Though many cases of eosinophilic gastroenteritis are reported in literature,eosinophilic pancreatitis,hepatitis and gastritis in a single patient has not been reported.Eosinophils are bone marrow derived leukocytes from the myeloid lineage.The pathophysiological manifestations of eosinophilic reactions are mediated by enzymes contained inside the cytoplasmic granules.The degranulation of granules releases the enzymes which are toxic to both parasites and host cells.Free radicals produced by the eosinophilic peroxidase and the respiratory burst oxidative pathway of the infiltrating eosinophils further enhances the damage.Eosinophils amplify the inflammatory cascade by secreting chemoattractants that recruit more eosinophils.Such chemoattractants include eotaxin,platelet-activating factor and the cytokine RANTES(regulated upon activation,normal T cell expressed,and secreted).Organ damage induced by eosinophilic infiltration of the tissues is through mediators released from the eosinophil granules.The causes of high eosinophil count can range from primary eosinophilia to those due to secondary eosinophilia.An increase in tissue eosinophilia may be seen with or without concurrent peripheral eosinophilia.Secondary or reactive eosinophilia is associated with a wide variety of conditions like infections(especially helminth parasites),allergic responses,neoplasms,connective tissue disorders,medications and endocrinopathies.The commonest cause of eosinophilia worldwide is infection by helminth parasites.In the developed world eosinophilia is mostly due to allergic reactions and a variety of other less common causes of eosinophilia.However,there are certain conditions which give rise to eosinophilia as well as systemic involvement.Many conditions which give rise to high eosinophil count can also have multiple systemic involvements.Some of those conditions are eosinophilic gastroenteritis(EGE),drug rash with eosinophilia and systemic symptoms(DRESS),eosinophilia associated with connective tissue disorders and inflammatory bowel diseases(IBD)and drug induced hypersensitivity reactions including drug induced liver injury(DILI).Drug induced hypersensitivity is a well known cause of eosinophilia.A number of drugs can induce hypersensitivity reactions.Traditional herbal medications are notorious for causing hypersensitivity and liver injuries.In East Asian countries,the use of traditional herbal products is quite popular for the remedy of a wide variety of ailments.Traditional Chinese Medicine(TCM)employs an array of herbal products for the treatment of various diseases.In particular,one of the commonest herbal remedies Polygonum multiflorum,is widely used in various forms and extracts.In China,especially,the use of herbal medication is hugely popular.The use of herbal medication without the prescription is very common.This practice often leads to complications like drug induced hypersensitivity and liver injuries.Here we present a case of 37 year old gentleman with similar history but much more complicated presentation.He presented to the hospital with abdominal pain,nausea,vomiting and fever.He had marked peripheral eosinophilia,elevated liver enzymes and bilirubin as well as elevated serum amylase and lipase levels.He had a longstanding history of eczema and three weeks prior to coming to the hospital he had taken a traditional Chinese medicine called Polygonum multiflorum.Then he began experiencing upper abdominal pain with on and off nausea and vomiting.He also had mild fever.Clinical investigations were not conclusive but demonstrated persistently elevated liver enzymes,bilirubin,serum amylase,lipase and eosinophil count.Biopsy from the stomach showed eosinophilic infiltration of the gastric mucosa.Autoimmune markers were negative.Computed tomography(CT)scan of the abdomen showed no evidence of pancreatitis but showed esophageal thickening and intrahepatic biliary stone.Upper gastrointestinal endoscopic examination revealed chronic gastritis.In view of prolonged prothrombin time(PT)and patient's refusal,liver biopsy could not be taken.He was given a clinical diagnosis of drug induced hypersensitivity leading to liver injury,pancreatitis and gastritis.Evidence of eosinophilic infiltration of the gastric mucosa further strengthened this diagnosis.He was prescribed omeprazole,magnesium isoglycyrrzhinate and Ursodeoxycholic acid(UDCA).He improved with supportive treatment and withdrawal of the Chinese medicine.CONCLUSIONEosinophilia with involvement of multiple organs can occur as a result of hypersensitivity reaction to certain drugs,Polygonum multiflorum,in our case.Drug induced hypersensitivity with eosinophilic infiltration should be considered as a possible etiology in patients with similar history.