Endoscopy Challenge #5 - March '12

3 year old with eosinophilic esophagitis comes in for follow up endoscopy.

History

3-year-old with previous history of eosinophilic esophagitis. Treated with diet restrictions and oral viscous budesonide. Follow-up endoscopy reveals healed eosinophilic esophagitis, with no evidence of candidal superinfection and a small, 3-4 mm nodule in distal third of the esophagus (Image 1). Increased vascularity was noted, blood vessels arising from the nodule and radiating in a circumferential fashion. The nodule biopsied and the pathologic diagnosis was:

Diagnosis

Eosinophilic granuloma.

Discussion

Pathology reading: squamous epithelium with patchy increase in intraepithelial eosinophils, focal eosinophilic micro abscesses and focally prominent intraepithelial lymphocytes (Image 2). Esophageal granulomas in the esophagus are rare in the literature. Eosinophilic granulomas have been sparsely reported in the stomach and duodenum of individuals with background allergic disorders or parasites [1-3]. Sizes can vary greatly and have been confused with malignant lesions. Gastric lesions are usually noted as ulcerated, while duodenal lesions are nodular in appearance. A review of the histologic characteristics of eosinophilic granulomas notes that eosinophilic cell infiltration is common, as is a generous hyperplasia of arterioles and venules in these patients [4]. These features were all noted in this case.

Authors:

  1. J. Antonio Quiros MD
  2. Maria Patino MD*

Department of Pediatric Gastroenterology and the Department of Surgical Pathology* California Pacific Medical Center.

References

  1. Asami, K., et al., Two Cases of Stomach Granuloma Caused by Anisakis-Like Larval Nematodes in Japan. The American Journal of Tropical Medicine and Hygiene, 1965. 14: p. 119-23.
  2. Ashby, B.S., P.J. Appleton, and I. Dawson, Eosinophilic Granuloma of Gastro-Intestinal Tract Caused by Herring Parasite Eustoma Rotundatum. British Medical Journal, 1964. 1(5391): p.1141-5.
  3. Cao, J., H. Luo, and Z. Gao, Gastric eosinophilic granuloma in China: case series. Digestion, 2005. 71(3): p. 176-8.
  4. Song, W.C., et al., Endoscopic findings and pathologic characteristics of gastric eosinophilic granuloma: a report of 18 patients. World Journal of Gastroenterology : WJG, 2006. 12(46): p.7542-6.