Clinical Resume
A 55-year-old man presented to his general practitioner (GP) with a 3-week history
of flu-like symptoms, pruritis, weight loss, and diarrhea. Initial investigations
showed eosinophilia, 32.2 × 109/L (normal range: 0 to 0.5 × 109/L) and a normal random glucose.
He was seen in a general medical clinic 3 weeks after the initial referral from GP
and, at this point, had polyuria and polydipsia. He was previously well and was on
no medication. He is a nonsmoker, drinks alcohol occasionally, and denies illicit
drug abuse. There had been no recent travel abroad. Physical examination was unremarkable.
Repeat investigations showed ongoing eosinophilia (33.5 × 109/L), elevated random blood glucose (15.9 mmol/L), raised hemoglobin A1c (HbA1c) (89 mmol/mol,
i.e., 10.3%), raised creatinine (171 µmol/L; 1.93 mg/dL), and normal liver function
tests. There were no ova, cysts, or parasites in urine or stool. Strongyloides, hepatitis,
and human immunodeficiency virus serology were negative, as were the antinuclear antibody
and antineutrophil cytoplasmic autoantibody. A cytogenetic analysis test and F1P1L1-PDGFRA
(to rule out eosinophilic leukemia) were also negative. Renal function normalized
with intravenous fluid support. Acute kidney injury was thought to be secondary to
diarrhea and osmotic diuresis. Computed tomography (CT) scan of the chest and abdomen
showed a generally swollen and bulky pancreas ([Fig. 1]).
Fig. 1 Computed tomography of the abdomen, abdomen shows an enlarged pancreas.
Management and Progress
In the context of eosinophilia, elevated HbA1c, and the CT findings, the diagnosis
of diabetes mellitus secondary to eosinophilic pancreatitis (EP) was thought to be
the most likely etiology, and he was commenced on insulin therapy. After 1 week, prednisolone
(40 mg/day) was initiated once the blood glucose levels were stabilized with insulin.
Immediately after starting glucocorticoids, the eosinophil count fell ([Fig. 2]), and insulin requirements decreased. After 2 months, the eosinophilic count was
near normal (0.8 × 109/L), and insulin was stopped. Steroids were weaned off over the next 8 weeks. The
patient has been off all the treatment for the last 7 years with eosinophil counts
just above the normal range (0.7 × 109/L) and the latest HbA1c, 7 years from the diagnosis, in September 2021, is 47 mmol/mol
(6.4%).
Fig. 2 A graphical representation of the rise and the sustained resolution of eosinophilia.
Discussion
EP is a rare disorder, first described in 1978,[1] with only < 20 cases reported thus far in the literature.[2]
[3] To the best of our knowledge, none of these cases presented diabetes mellitus as
the cardinal symptom. Patients were predominantly male, generally in their fifth or
sixth decade. Presenting symptoms were very nonspecific such as varying degrees of
abdominal pain, fatigue, nausea, vomiting, diarrhea, obstructive jaundice, and weight
loss. In most reported cases, pancreatic infiltration with eosinophils was noted retrospectively
either in the surgically removed specimen or during the autopsy. Differential diagnoses
include pancreatic malignancy, autoimmune pancreatitis, alcoholic pancreatitis, parasitic
infections, and systemic mastocytosis.
Conclusion
We presented a rare case of EP as part of hypereosinophilic syndrome with diabetes
mellitus at presentation but with minimal involvement of other systems. This was a
unique situation in which steroids, which usually cause hyperglycemia, were effectively
used to treat diabetes mellitus.
