The intent of this case report isto emphasis the multiple possible medical conditions that may result from the excessive intake of milk. In the reported case, the presence of significant anemia, with hypoalbuminemia and eosinophilia were the critical elements that hallmarked the eventual diagnosis of eosinophilic gastroenteritis. Each of the critical components of the history, did however, suggest other potential diagnoses.
The initial concern was the severe iron deficiency anemia that is common in toddlers who consume large amounts of cow’s-milk. In fact, is the most common cause during the second year of life. CM impacts iron storages at all levels and it is an iron poor food. Its high content of casein, calcium, phosphorus, and a low Vitamin-C decreases the bioavailability of the iron it contains; furthermore CM has been associated with chronic GI losses . The non-improvement at follow-up necessitated further evaluation.
The explanation of the hypoalbuminemia was initially less clear.Protein losing enteropathy associated with (or caused by) cow’s milk ingestion has also been described although is rare, and it mechanism is not well understood[4,5]. It is hypothesized that the anemia and ferropenia negatively impact tissue metabolism and contribute to mucosal barrier dysfunction .The original anemia was likely caused by excessive cow’s milk ingestion, and the uncommon, but reported,milk associated protein losing enteropathy was advanced as a further complication of the excessive cow’s milk ingestion .
The underlying atopic dermatitis with food allergy (shrimp) was originally considered a separate disease process, resulting in eosinophilia. However, the continued clinic picture at the GI clinic visit necessitated the esophagogastroduodenoscopy and colonoscopy with biopsies. The findings were compatible with pan-eosinophilic enteritis with associated protein losing enteropathy. First described in 1937, eosinophilic gastroenteritis (EGID) refers to a histologic infiltration of eosinophils in the GI tract at any point from the proximal esophagus to the anus[7,8]. A rare condition, it can present at any age; the peak incidence is seen in pediatric patients < 5yr, and apublication of a small number of pediatric “allergic gastroenteropathy”cases (EGID) is of historical interest[7-9].The pathophysiology ofeosinophilic gastroenteritis is not completely understood. Both IGE-mediated inflammation and non-IgE-mediated phenomena play a role[7,8].
There are 3 categories of EG as described by Klein in 1970, mucosal, muscular, and serosal form. Symptoms vary according to the affected layer. The most common symptoms are abdominal pain, bloating, weight loss, dysphagia and vomiting[7,8]. Uncommon presentations include acute abdominal pain that mimics appendicitis. Colonic obstruction, abdominal distention, eosinophilic ascites and bowel perforation can occur, based on the bowel wall layer involved. A Medscape review of eosinophilic enteritis is available (https://www.medscape.com/viewarticle/772972
Protein losing enteropathy and failure to thrive with pediatric EGID are typically seen in patient who have severe mucosal involvement[7,8].A Medscape review of pediatric protein losing enteropathy in 2018 did mention EGID as a possibility. (https://emedicine.medscape.com/article/931647-overview
).It is known that intestinal mast cells are significantly increased in the intestine in EGID, possibly causing increased intestinal permeability and protein loss[7,8].
The diagnostic workup for exaggerated gastrointestinal mucosal eosinophilia is directed at identifying allpotential causes of tissue eosinophilic related conditions including, parasitic infestations, myeloproliferative dysplasia, congenital immune-deficiencies, HIV infection and systemic mastocytes and EGID’s[7,8].
There is a lack of strong evidence regarding the best treatment for pediatric pan-EGID.EGID is considered an Type 2 (TH2
) immune disease, but routine IgE allergy testing results have been less useful, and empiric elimination of allergy-associated foods (milk, wheat, eggs, peanut and soy) is the most used strategy with variable results in terms of symptom relief[7,8]. Corticosteroids have been used in adults with success. Topical steroids are used to minimize the side effects profile and have been proven effective[12-14]. In the reported case the avoidance of cow’s milk and swallowed corticosteroids (Budesonide) was successful, with resolution of anemia, hypoalbuminemia, and the gastrointestinal eosinophilia. The therapy options for EGID are reviewed in a recent Medscape report (https://www.medscape.com/viewarticle/772972
). The natural history of EGID and pan-EGID in children is not known. Long-term surveillance is necessary.Funding source:
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