In the name of GOD

Case 1

cc:diarrhea PI:67y/o woman with cheif complaint of diarrhea since 2 month ago

H+: diarrhea was watery not bloody, frequencies 6-7 time per day.

H_: symptom not associated with fever, feeding, abd pain,tenesmus,nausea,vomitimg,wt loss , anorexia or GI bleeding .

• PMH: neg

• DH: neg• F/H:neg

• Allergy/H:neg

• PH/E: NL

CBC:

WBC:7600 HB:10/9 MCV:83 MCH:28 PLT:230000

Ure:20 cr:1 Na:135 K:3/4 BS:115 AST,ALT ,ALKP,Bil:nl ESR:15 CRP:-

S/E:WBC, RBC, OB ,op _

S/C:-

U/A:-

• Trans Abd & pelvic sono: NL

• Upper & Lower GI endoscopy: NL

• Biopsies were taken from duodenal mucosa & colon

Case 2Cc:abd pain,lower extremities edema

PI: 41y/o man was referred with cheif complaint of abd pain & lower extremities edema since 3 month ago

H+: pain aggravated with feeding & associated nausea , vomiting &melena too.H_:not colicky , radiated to area, awake at night or Wt loss.

• PMH:neg

• Drug/ H: H2blocker

• F/H:: Neg history of GI disease ,hepatitis,or cancer in his family

• Allergy -

• PH/E: pale PR:120 Epigastric pain ,lower extremities pitting edema +2

• CBC:• WBC: 6000 EOS:600(10%) HG: 4 MCV: 65 PLT:480000

• BUN.Cr.Na,K.AST,ALT,BIL,ALKP,INR:NL

• Alb:3.2 total pr:6

• Ferritin:7 fe:118 TIBC:286 Anti TTG:NL

• S/E:WBC_ RBC 10-12 O/P:_ OB:+

• U/A:NL

• Upper GI ENDOSCOPY: There were 2 clean-based superficial ulcer without bleeding in ant, largest diameter was 6-8mm.multiple biopseis were taken

• Trans abd Sonography: NL

• Echocardiography: NL

Case 3 Cc:epigastric pain

PI:16y/o man with cheif complaint of epigastric pain since one month ago .

H+: N/V & intermittent bloody diarrhea since 2 week ago. history 4kg wt loss & abd distention during last month.

H_: pain not colicky or radiated to area,not exacerbated or improve with food Or awake him at night.

PMH:•Neg history of problem or surgical in past medical

Allergy +

hepatitis neg

Drug : Neg

F/H: Neg history of GI disease ,hepatitis,or cancer in his family

• R .O.S:• NO headache,vertigo or hearing loss• NO hair loss,skin change• NO dry mouth or eye• NO dysphagia or odynophagia• NO chest pain or dyspnea abdominal distentionSexual development nlNO swelling of joint or stiffness

Physical Exam•Pt not ill or toxic •T:37.1 Ax at night BP: 110/80, PR: 89, RR :21 O2 sat: 95%• no pale or ichteric no tenderness on PNs•No lymphadenopathy•noTemporal wasting•No Hoarseness• jvp Nl & no thyromegaly

•Chest examination•Revealed equal bilateral breath sounds,with no wheezes & bilateral clearShe had a normal S1&S2 sound and no murmurs.

•Abdomen•Soft with nontenderness, no masses or hepatosplenomegaly.• shifting dulness+ No hair loss or gynecomastia or spider angioma

Ext• edema lower ext 1+• no rash, telangiectasia, or other skin changes•no clubbing.no palmar erythema•joints revealed no warmth, swelling, erythematic, tender prox muscle

• WBC:10300 (PMN;47% lymph:22% Eos:30%) EOS:3100

• Hb:13.8• MCV:84• MCH:26• MCHC:31• PIT:420000

Lab DataBS:105 AsT:33 AlT:11 Na:135 Bill(t):0.4K:4.2 Bill(d):0.2 alkp:135 Alb:4 total pr:7.8INR:1Urea:44 ESR:2Cr:1.1 LDH:440

• HbsAg- HbcAb- HcvAb - HIVAb –

• Anti TTG Ab:nl

• S/E: WBC:MANY RBC:0 O/B:- O/P:- CYST:-

• S/C:-• U/A:NL

Trans abd Sonography:Liver nl in size & echoCBD diameter nlPortal vein nlSplenomegaly negLymphadenopathy negKidney nl in echo & sizeModerate ascites

• Problem list:

• A young man with epigastric pain since 1month ago.4kg wt loss,N/V,BLOODY diarrhea,ascites,eosinophilia in CBC(EOS>3100)

Abd paracentesis

• Appearance:yellow• WBC:990O PMN:95 LYM:5• RBC:0• LDH:321• GLU:80• Pr:5/8• Alb:3/3 SAAG:0.7(low SAAG)

• Problem list:

• A young man with• epigastric pain & N/V since 1month ago.• 4kg wt loss,• intermittent BLOODY diarrhea,• low SAAG ascites• eosinophilia CBC(EOS>3100)

Eosinophil-associated diseases and disorders

ALLERGIC DISORDERSAtopic: dermatitis,Asthma,Rhinitis syndromes,Medication-related eosinophilia

INFECTIOUS DISEASES Parasitic infections,Fungal infections,HIV and other retroviral infections

HEMATOLOGIC AND NEOPLASTIC DISORDERS Hypereosinophilic syndromes ,Mastocytosis,Leukemia,Lymphoma,Other malignancies

RHEUMATIC DISEASE Eosinophilia-myalgia syndrome and toxic oil syndrome ,Idiopathic eosinophilic synovitis ,Vasculitis

MISCELLANEOUS CAUSESA:

adrenal insufficiency ,Atheroembolic disease,Immunodeficiency states

Disease with specific organ envolment

• ADA:2.3

• Gram neg &Gram pos bac were not seen IN smear & culture

• Laparoscopic peritoneal biopsy: کبد بررسینشد دیده خاصی ضایعه شکم وکل امنتوم

• Biopsy was taken from peritoneum

• Upper GI endoscopy:

• Esophagus:upper,middle,lower third were NL• Stomach:fundus,body & antrum were NL• Duodenum:Bulb & 2nd part were NL

Upper GI ENDOSCOPY

• lower GI endoscopy:Anus,desending ,transvers part,ascending & cecum were NL

• The mucosa has angioectasia in rectum & sigmoid

• Biopsies were taken from duodenal mucosa & colon