Scientific Letter
Hematemesis as debut of eosinophilic gastroenteritis in infants
Hematemesis como debut de gastroenteritis eosinofílica en lactantes
María Soriano-Ramos
, Enrique Salcedo Lobato, Yolanda Rodríguez Gil, Enrique Medina Benítez, Pedro Urruzuno Tellería
Corresponding author
Departamento de Pediatría, Hospital Universitario 12 de Octubre, Madrid, Spain
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array:1 [ 0 => array:4 [ "autoresLista" => "María Soriano-Ramos, Enrique Salcedo Lobato, Yolanda Rodríguez Gil, Enrique Medina Benítez, Pedro Urruzuno Tellería" "autores" => array:5 [ 0 => array:4 [ "nombre" => "María" "apellidos" => "Soriano-Ramos" "email" => array:1 [ 0 => "sorianoramosmaria@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Enrique" "apellidos" => "Salcedo Lobato" ] 2 => array:2 [ "nombre" => "Yolanda" "apellidos" => "Rodríguez Gil" ] 3 => array:2 [ "nombre" => "Enrique" "apellidos" => "Medina Benítez" ] 4 => array:2 [ "nombre" => "Pedro" "apellidos" => "Urruzuno Tellería" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Pediatría, Hospital Universitario 12 de Octubre, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hematemesis como debut de gastroenteritis eosinofílica en lactantes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 676 "Ancho" => 900 "Tamanyo" => 202661 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">High-magnification microscopic view of gastric mucosa revealing erosive gastritis with a significant eosinophil component in the inflammatory infiltrate (>30<span class="elsevierStyleHsp" style=""></span>cells/HPF). HE stain. 400× magnification.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Eosinophilic gastroenteritis (EGE) is a rare type of gastroenteritis characterised by eosinophilic inflammation in different segments of the GI tract in the absence of known causes for eosinophilia (parasitic infestation, drug toxicity, malignancy, inflammatory bowel disease or hypereosinophilic syndrome, among others).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical manifestations of EGE are nonspecific and vary based on the location and the depth of eosinophilic infiltration in the layers of the gastrointestinal tract, and may include chronic abdominal pain, vomiting, upper or lower gastrointestinal bleeding, diarrhoea and/or ascites.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Its aetiology and pathophysiology is not understood, although they seem to be involve hypersensitivity mechanisms, and the antigen involved most frequently in infants is cow's milk protein (CMP).<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a> The diagnosis is confirmed by histological examination, and at present there is no established threshold for the definition of eosinophilia in the gastrointestinal tract.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Eosinophilic gastroenteritis is rare in infants and its presentation can vary widely, so diagnosis requires a high level of suspicion. In patients that present with upper gastrointestinal bleeding, the disease may range from mild forms that are well tolerated to severe forms leading to anaemia or haemodynamic instability that may require transfusions. We present the cases of two infants with eosinophilic gastroenteritis and gastritis managed in our hospital.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Case 1: infant aged 4 months, previously healthy, who in the context of acute gastroenteritis had three episodes of vomiting with presence of coagulated blood in the vomit. He had not received ibuprofen and had been fed infant formula since age 1 month. At the time of evaluation, he was in good general health with normal vital signs. He had several eczematous lesions in the trunk and retroauricular area. The complete blood count revealed a haemoglobin concentration of 11.2<span class="elsevierStyleHsp" style=""></span>g/dL, a white blood cell count of 18<span class="elsevierStyleHsp" style=""></span>800<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">3</span> (18.9% neutrophils, 56.4% lymphocytes, 22.8% monocytes, 1.8% eosinophils, 0.1% basophils) and a platelet count of 283<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span>. The abdominal ultrasound findings were normal. Fresh blood was found on gastric suction, and oesophagogastroduodenoscopy revealed erosions in the antral mucosa and diffuse fibrin-coated lesions in the gastric body and a pale duodenal mucosa. Histological examination (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) revealed a significant although heterogeneous eosinophilic component in the duodenal mucosa (>20 eosinophils/high power field [HPF] with focal involvement) and a mixed inflammatory cellular infiltrate in the gastric mucosa that included abundant eosinophils (25–30 eosinophils/HPF). The infant was managed by switching to elemental formula, to which he showed a favourable response. Allergen-specific IgE testing detected low titres of antibodies against CMP (casein, 0.44<span class="elsevierStyleHsp" style=""></span>kIU/L; β-lactoglobulin, 0.24<span class="elsevierStyleHsp" style=""></span>kIU/L, α-lactalbumin, 0.12<span class="elsevierStyleHsp" style=""></span>kIU/L). Followup: from age 12 months, CMP was progressively reintroduced in the diet without negative repercussions.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Case 2: infant aged 2 months, previously healthy, who had three episodes of vomiting with fresh blood and a darker-than-normal bowel movement the day before evaluation. She presented with urticarial-like lesions in the lower extremities that had developed 24<span class="elsevierStyleHsp" style=""></span>h earlier, which she had also exhibited transiently at age 1 month. The patient had been formula-fed from birth. She was in good general health at the time of physical examination, whose salient findings were a marked paleness of the skin and mucosae and a red and swollen exanthema in the lower extremities that was spreading to the upper limbs. Auscultation of heart sounds revealed tachycardia, with 165 beats per minute, and a mild systolic murmur. The findings of the complete blood count were: haemoglobin concentration of 6.5<span class="elsevierStyleHsp" style=""></span>g/dL, white blood cell count of 16<span class="elsevierStyleHsp" style=""></span>700<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">3</span> (24.2% neutrophils, 61.3% lymphocytes, 13.5% monocytes, 0.7% eosinophils, 0.3% basophils) and 338<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>platelets/mm<span class="elsevierStyleSup">3</span>, with normal features in the peripheral blood smear. The results of the blood chemistry and coagulation panel were normal, and haematuria was not detected in the urine test strip. The patient underwent gastric lavage and suction, and blood was not found in the recovered contents. Since the loss of blood had caused haemodynamic instability, the patient received a transfusion of packed red blood cells, which led to improvement of symptoms and laboratory parameters. Oesophagogastroduodenoscopy revealed diffuse erythema and multiple fibrinous lesions in the gastric mucosa and a normal duodenal mucosa. Biopsy examination revealed superficial gastritis and a mixed inflammatory cell infiltrate with a predominance of eosinophils, with up to 30 eosinophils/HPF (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The patient was switched to an exclusive diet of elemental formula, with resolution of symptoms. Allergen-specific IgE testing detected antibodies against CMP (casein, 1.24<span class="elsevierStyleHsp" style=""></span>kIU/L; β-lactoglobulin, 2.82<span class="elsevierStyleHsp" style=""></span>kIU/L; α-lactalbumin, 0.14<span class="elsevierStyleHsp" style=""></span>kIU/L; cow's milk, 3.69<span class="elsevierStyleHsp" style=""></span>kIU/L). Followup: the patient is still keeping a CMP-free diet, which is well tolerated.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The two patients whose cases we present here had onset during infancy with upper gastrointestinal bleeding and a different degree of haemodynamic impact, and received final diagnoses of eosinophilic gastroenteritis and eosinophilic gastritis, respectively. Recently, Choi et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> published a study assessing the clinical, endoscopic and histologic features and the response to treatment of 13 children with a histological diagnosis of EGE. They found that the most prevalent symptom at onset in the infant group (8 patients) was haematemesis (7 patients, 87.5%), followed by melena (2 patients, 25%). In contrast, recurrent abdominal pain was the predominant symptom in the group of children aged more than 1 year (60%). Furthermore, CMP was the allergen most frequently suspected to be involved based on the clinical manifestations, suspected in 76.9% of patients, and all infants in this study responded favourably to switching from cow's milk to extensively hydrolysed/elemental formula. These findings are consistent with the outcomes of the two patients managed in our hospital, although it is important to keep in mind that absence of peripheral eosinophilia or negative results of specific IgE assays are not sufficient to exclude a diagnosis of EGE.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Soriano-Ramos M, Salcedo Lobato E, Rodríguez Gil Y, Medina Benítez E, Urruzuno Tellería P. Hematemesis como debut de gastroenteritis eosinofílica en lactantes. An Pediatr (Barc). 2018;88:351–353.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 676 "Ancho" => 900 "Tamanyo" => 201379 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Microscopic image of duodenal mucosa. Significant mixed inflammatory cell infiltrate with eosinophils. HE stain. 400× magnification.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 676 "Ancho" => 900 "Tamanyo" => 202661 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">High-magnification microscopic view of gastric mucosa revealing erosive gastritis with a significant eosinophil component in the inflammatory infiltrate (>30<span class="elsevierStyleHsp" style=""></span>cells/HPF). HE stain. 400× magnification.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eosinophilic gastritis in children: clinicopathological correlation disease course, and response to therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H.M. Ko" 1 => "R.A. Morotti" 2 => "O. Yershov" 3 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 6 | 11 |
| 2024 October | 53 | 43 | 96 |
| 2024 September | 71 | 46 | 117 |
| 2024 August | 65 | 62 | 127 |
| 2024 July | 72 | 44 | 116 |
| 2024 June | 60 | 39 | 99 |
| 2024 May | 42 | 62 | 104 |
| 2024 April | 48 | 31 | 79 |
| 2024 March | 60 | 23 | 83 |
| 2024 February | 43 | 43 | 86 |
| 2024 January | 49 | 27 | 76 |
| 2023 December | 69 | 21 | 90 |
| 2023 November | 48 | 27 | 75 |
| 2023 October | 47 | 23 | 70 |
| 2023 September | 46 | 22 | 68 |
| 2023 August | 47 | 17 | 64 |
| 2023 July | 58 | 34 | 92 |
| 2023 June | 60 | 26 | 86 |
| 2023 May | 73 | 22 | 95 |
| 2023 April | 65 | 24 | 89 |
| 2023 March | 83 | 21 | 104 |
| 2023 February | 60 | 19 | 79 |
| 2023 January | 43 | 21 | 64 |
| 2022 December | 65 | 21 | 86 |
| 2022 November | 72 | 37 | 109 |
| 2022 October | 58 | 40 | 98 |
| 2022 September | 43 | 47 | 90 |
| 2022 August | 53 | 49 | 102 |
| 2022 July | 44 | 43 | 87 |
| 2022 June | 42 | 33 | 75 |
| 2022 May | 42 | 48 | 90 |
| 2022 April | 54 | 46 | 100 |
| 2022 March | 60 | 56 | 116 |
| 2022 February | 48 | 34 | 82 |
| 2022 January | 81 | 48 | 129 |
| 2021 December | 53 | 43 | 96 |
| 2021 November | 64 | 43 | 107 |
| 2021 October | 86 | 86 | 172 |
| 2021 September | 45 | 43 | 88 |
| 2021 August | 52 | 41 | 93 |
| 2021 July | 58 | 36 | 94 |
| 2021 June | 53 | 51 | 104 |
| 2021 May | 72 | 46 | 118 |
| 2021 April | 152 | 53 | 205 |
| 2021 March | 78 | 30 | 108 |
| 2021 February | 64 | 22 | 86 |
| 2021 January | 56 | 24 | 80 |
| 2020 December | 61 | 16 | 77 |
| 2020 November | 66 | 14 | 80 |
| 2020 October | 49 | 20 | 69 |
| 2020 September | 64 | 22 | 86 |
| 2020 August | 39 | 9 | 48 |
| 2020 July | 51 | 14 | 65 |
| 2020 June | 59 | 11 | 70 |
| 2020 May | 44 | 19 | 63 |
| 2020 April | 41 | 15 | 56 |
| 2020 March | 39 | 21 | 60 |
| 2020 February | 38 | 10 | 48 |
| 2020 January | 50 | 16 | 66 |
| 2019 December | 59 | 23 | 82 |
| 2019 November | 53 | 24 | 77 |
| 2019 October | 50 | 15 | 65 |
| 2019 September | 32 | 17 | 49 |
| 2019 August | 49 | 21 | 70 |
| 2019 July | 49 | 26 | 75 |
| 2019 June | 33 | 23 | 56 |
| 2019 May | 53 | 27 | 80 |
| 2019 April | 78 | 33 | 111 |
| 2019 March | 48 | 25 | 73 |
| 2019 February | 51 | 22 | 73 |
| 2019 January | 35 | 14 | 49 |
| 2018 December | 56 | 24 | 80 |
| 2018 November | 58 | 31 | 89 |
| 2018 October | 59 | 13 | 72 |
| 2018 September | 44 | 13 | 57 |
| 2018 August | 3 | 0 | 3 |
| 2018 July | 4 | 1 | 5 |
| 2018 May | 0 | 7 | 7 |
| 2018 April | 0 | 3 | 3 |
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