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LETTER TO EDITOR
Year : 2016  |  Volume : 23  |  Issue : 2  |  Page : 120-121  

Esophageal eosinophilia in secondary adrenal insufficiency


1 Department of Medicine, Medical College, Kolkata, West Bengal, India
2 Department of Medicine, ESI Medical College, Kolkata, West Bengal, India

Date of Web Publication21-Apr-2016

Correspondence Address:
Krishnarpan Chatterjee
B-7/11, Diamond Park, Diamond Hoarbour Road, Joka, Kolkata - 700 104, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-8229.181005

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How to cite this article:
Sen C, Chatterjee K. Esophageal eosinophilia in secondary adrenal insufficiency. J Fam Community Med 2016;23:120-1

How to cite this URL:
Sen C, Chatterjee K. Esophageal eosinophilia in secondary adrenal insufficiency. J Fam Community Med [serial online] 2016 [cited 2020 Aug 6];23:120-1. Available from: http://www.jfcmonline.com/text.asp?2016/23/2/120/181005



Sir,

A 50-year-old female presented with an insidious history of dysphagia to solids and recurrent vomiting of 3 months' duration associated with abdominal pain, nausea, and weight loss. She had a history of prolonged use of over the counter steroids for rheumatoid arthritis. On examination, she had alabaster skin, blood pressure of 90/60 mm of Hg, and low volume pulse. She had diffuse per-abdominal tenderness without guarding or rigidity. There was no organomegaly. Other system examination was normal. A clinical diagnosis of secondary adrenal insufficiency was made and intravenous (IV) dexamethasone was started empirically with IV fluid replacement. Her peripheral smear revealed total leukocyte count of 4000/cu.mm with eosinophilia (absolute eosinophil count = 1000, 25%). She had hyponatremia (Na - 120 mEq/L) and normal potassium levels (K - 5.3 mEq/L). Her basal cortisol and adrenocorticotropic hormone was low (4 µg/dL and 12 pg/mL). Cortisol failed to rise above 18 µg/dL 30 min after 250 µg of cosyntropin. Endoscopy showed transient esophageal rings and linear furrows resembling idiopathic eosinophilic esophagitis [Figure 1] and [Figure 2]. Biopsy taken from multiple sites revealed mucosal eosinophils >20 per high power field. She had episodes of hypoglycemia which were managed with IV dextrose. She then developed shock refractory to IV hydrocortisone and inotropes and suffered a cardiac arrest on the 4th day of admission and could not be resuscitated.
Figure 1: Linear furrows in esophagus

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Figure 2: Transient esophageal rings

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Adrenal insufficiency is a cause for peripheral blood eosinophilia. Esophageal eosinophilia can have many causes which must be excluded before a diagnosis of idiopathic eosinophilic esophagitis is made.[1] Rodrigo et al. demonstrated that intraepithelial eosinophilia as described in the diagnostic criteria for eosinophilic esophagitis can be seen in other diseases as well.[2] Endoscopic and histopathological features consistent with eosinophilic esophagitis have not been described before in association with eosinophilia in secondary adrenal insufficiency. It is important to rule out underlying systemic causes before a diagnosis of eosinophilic esophagitis is made.

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   References Top

1.
Dellon ES, Gonsalves N, Hirano I, Furuta GT, Liacouras CA, Katzka DA; American College of Gastroenterology. ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Am J Gastroenterol 2013;108:679-92.  Back to cited text no. 1
    
2.
Rodrigo S, Abboud G, Oh D, DeMeester SR, Hagen J, Lipham J, et al. High intraepithelial eosinophil counts in esophageal squamous epithelium are not specific for eosinophilic esophagitis in adults. Am J Gastroenterol 2008;103:435-42.  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2]


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