Critical Care: Inflammatory Diseases Affecting the Lung |

Acute Cholecystitis and Duodenitis: A Rare Case Presentation of Churg Strauss Syndrome FREE TO VIEW

Reem Mahdawi, MD; Sarwan Kumar, MD; Zain Kulairi, MD; Salwan Almutar, MD; Vesna Tegeltija, MD
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Wayne State University, Crittenton Hospital, Rochester, MI

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):301A. doi:10.1016/j.chest.2016.08.314
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SESSION TITLE: Inflammatory Diseases Affecting the Lung

SESSION TYPE: Student/Resident Case Report Slide

PRESENTED ON: Monday, October 24, 2016 at 11:00 AM - 12:00 PM

INTRODUCTION: The Churg Strauss Syndrome (CSS) was first described in 1951 by Churg and Strauss. It is an eosinophilic tissue infiltration, granuloma formation and a necrotizing vasculitis involving small to medium-sized vessels. It presents as Asthma, eosinophilia and sinus involvement. We are reporting an atypical presentation of CSS with gastrointestinal involvement presented as Cholecystitis, duodenitis and liver infilterate

CASE PRESENTATION: A 47 year-old woman with past medical history of Asthma, sinusitis, migraine headache; presented with intermittent epigastric pain, nausea and vomiting. Examination was significant for right upper quadrant pain and guarding. Blood work was consistent with WBC count of 17000 with 32% eosinophil. Abdominal U/S demonstrated thickening of gallbladder with sludge but no stone, endoscopy showed thickening of duodenal bulb along with duodenal polyp, HIDA scan showed biliary dyskinesia EF 18%. CT scan of the abdomen showed 2 mm hypodensity within the right hepatic lobe along with haziness of the porta hepatis. Patient subsequently had laparoscopic cholecystectomy. Biopsy of the liver and resected gallbladder were consistent with necrotizing eosinophilic vasculitis which fills the criteria of CSS. P-ANCA titers and IgE level were both elevated. IV Steroid was started with significant symptoms improvement in 24 hours. Patient was discharged home on oral prednisone and instructed to follow up with a rheumatologist.

DISCUSSION: There are six criteria that can be used for the classification of CSS. These Criteria are: (1) Bronchial asthma; (2) Eosinophilia >10% by differential WBC count; (3) Mononeuropathy or polyneuropathy; (4) Non-fixed pulmonary infiltrates on roentgenography; (5) Paranasal sinus abnormality; (6) Biopsy containing a blood vessel with extravascular eosinophils. Four of these criteria were manifested in our case. Masi et al reported that the existence of four or more of these six criteria has a specificity of 99.7%. Pulmonary symptoms are the most common clinical features of CSS. Involvement of other systems can result in symptoms related to peripheral neuropathy, myocarditis, glomerulonephritis and palpable purpuric lesions of the skin. Gastrointestinal complications of CCS is common including gastroenteritis, ileac or colonic involvement. Cholecystitis and duodenitis are rare complications of CSS specifically and vasculitis in general. In a study that was done on patients with vasculitis and GI involvement, cholecystitis presented only in 5% of the patients.

CONCLUSIONS: Although abdominal complaints rarely appeared as an initial symptom in the patients with CSS, this syndrome should be taken into consideration when the patient presents with abdominal pain of unknown origin, has eosinophilia, and history of asthma or allergic rhinitis.

Reference #1: Nishie, M., & Tomiyama, M. (2003). Acute cholecystitis and duodenitis associated with Churg-Strauss syndrome. Hepato-gastroenterology, 50(52), 998-1002. Retrieved December, 2015

DISCLOSURE: The following authors have nothing to disclose: Reem Mahdawi, Sarwan Kumar, Zain Kulairi, Salwan Almutar, Vesna Tegeltija

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