An unusual infection on an unusual gastroenteritis
A 35-year-old lady was admitted due to fever (39°C), abdominal pain, diarrhea and a non-productive cough for 3 days. She reported a history of asthma, atopic dermatitis, nephrolithiasis and smoking (30 pack/year). Her abdominal problems started 1 year ago when she underwent multiple urgent or semi-elective operations: appendectomy with subsequent gallbladder removal, followed by diagnostic laparotomy (6 months ago) with biopsies from a thickened jejunum to identify evidence of eosinophilic enteritis (muscular and serosal layers). She received treatment with steroids that was discontinued 2 months prior to admission.\nOn admission she presented with tachypnea, tachycardia, fever, and fine crackles in the right upper pulmonary field. Abdominal examination identified diffuse rebound tenderness and ascites. Chest-radiograph showed a consolidation in the right upper pulmonary field (), air blood gases (ABGs) revealed hypocapnea, and blood tests showed leukocytosis (without eosinophilia), high CRP and D-dimers, low albumin and marginally low sodium (). She received oxygen (28%), i.v. clarithromycin and cefuroxime, fluids, ranitidine, analgesics, and low-molecular-weight heparin subcutaneously.\nBecause of the severe clinical picture, impaired ABGs and the lung infiltrate, she underwent a ventilation/perfusion scan indicating a low probability for PE. On day 2 she had an unenhanced (due to strong history of allergy and no time for desensitization) spiral abdominal CT (), which showed a large amount of free fluid collection and thickening of several small bowel loops, without evidence of perforation. She did not consent to abdominal paracentesis. Viral and microbiology serological tests, as well as blood, urine and stool cultures were screened. Sputum induction gave suboptimal material for cultures.\nThe patient gradually improved. An upper GI endoscopy was unremarkable and biopsies showed mild gastritis. As diarrhea gradually improved and ceased, and given that the patient had twice had a lower GI endoscopy over the previous months, with unremarkable findings, a third colonoscopy was postponed. PPD was negative. She underwent a spiral chest-CT negative for PE, while the lung lesion resolved. Her immunological tests showed very high IgE, with IgA, IgM, IgG, RF, ANA, ANCA within normal values. Hepatotropic viruses, adenovirus, CMV, HIV, EBV, Coxiella burnetii, Yersinia enterocolitica, and Entamoeba histolytica were negative. Stool for parasites and stool-urine-blood cultures were also negative. On admission the patient had a titer for Legionella sp. IgG 1/64 in serum which, when repeated at week 4 from the onset of illness, diagnostically rose to titer 1/128. Urinary test for Legionella was not performed and PCR for Legionella was unavailable from our lab at that time. The final diagnosis for this patient was Legionella pneumophila pneumonia – eosinophilic gastroenteritis.\nAbbreviations: CT, computed tomography; CMV, cytomegalovirus; HIV, Human Immunodeficiency Virus; EBV, Epstein Barr Virus\nShe completed 14 days of antibiotic treatment and had for her EG prednisolone 40 mg slowly tapered, ranitidine 300 mg, ketotifen, and calcium and vitamin-D supplementation. The patient had a straightforward recovery, and she subsequently underwent an MRI-enteroclysis to further study the affected small bowel (). Three years after the episode she remains asymptomatic without relapses.