What is the treatment for eosinophilia (eos) associated with diarrhea?

Treatment of Eosinophilia Associated with Diarrhea

The treatment for eosinophilia associated with diarrhea depends on the underlying cause, with parasitic infections requiring specific antiparasitic medications, while eosinophilic gastroenteritis typically responds to oral corticosteroids.

Diagnostic Approach

First, determine the cause of eosinophilia with diarrhea:

1. Parasitic infections - Most common treatable causes

   • Obtain concentrated stool microscopy or fecal PCR
   • Consider travel history to endemic areas
   • Look for specific symptoms (abdominal pain, diarrhea, weight loss)

2. Eosinophilic gastroenteritis/colitis - Primary eosinophilic disorder

   • Requires endoscopy with biopsy showing eosinophilic infiltration
   • Often associated with history of atopy (asthma, eczema, allergic rhinitis)

Treatment Algorithm

For Parasitic Infections

1. Hookworm (Ancylostoma duodenale/Necator americanus):

   • Albendazole 400 mg daily for 3 days 1
   • Consider prednisolone 40-60 mg daily in severe disease 1

2. Strongyloidiasis:

   • Ivermectin 200 μg/kg/day for 1-2 days 2

3. Whipworm (Trichuris trichiura):

   • Mebendazole 100 mg twice daily in combination with ivermectin 200 μg/kg once daily for 3 days 1

4. Threadworm/Pinworm (Enterobius vermicularis):

   • Albendazole 400 mg twice daily for 21 days with monitoring of liver function and full blood count 1
   • Alternative: Albendazole 400 mg or mebendazole 100 mg as a single dose 1

5. Cystoisosporiasis (Cystoisospora belli):

   • For prolonged symptoms: Trimethoprim-sulfamethoxazole 960 mg twice daily for 7 days 1
   • Alternative: Ciprofloxacin 500 mg twice daily for 7 days (less effective) 1

For Eosinophilic Gastroenteritis/Colitis

1. First-line therapy:

   • Oral prednisone/prednisolone 30-60 mg/day (0.5-1 mg/kg/day) for 2-3 weeks 2, 3
   • Taper gradually based on clinical and laboratory response

2. For maintenance or steroid-sparing:

   • Consider elimination diets if food allergies are suspected
   • Biologic agents for refractory cases:
     • Anti-IL-5 therapies (mepolizumab)
     • Anti-IL-5 receptor antibodies (benralizumab) 2

Monitoring and Follow-up

1. Monitor eosinophil counts regularly during treatment
2. Assess resolution of symptoms (diarrhea, abdominal pain)
3. For parasitic infections, repeat stool examination after treatment completion
4. For eosinophilic gastroenteritis, consider repeat endoscopy with biopsy to confirm histological improvement

Special Considerations

• Steroid side effects: Monitor for hyperglycemia, hypertension, and adrenal suppression with prolonged use
• Refractory cases: Consider specialist referral (gastroenterology, infectious disease, or allergy)
• Candida infection: May occur with topical steroid treatment; manage with topical antifungals while continuing steroids 1

Treatment Pitfalls to Avoid

1. Failure to identify underlying cause: Always determine if eosinophilia is primary or secondary
2. Inadequate treatment duration: Complete full course of antiparasitic treatment
3. Premature steroid tapering: May lead to symptom relapse in eosinophilic gastroenteritis
4. Missing concomitant infections: Consider multiple parasitic infections in returning travelers
5. Overlooking drug-induced eosinophilia: Review medication history (clopidogrel, ibuprofen, hormonal agents) 4

The most effective approach is to identify and treat the specific cause of eosinophilia with diarrhea rather than treating symptoms alone, as outcomes for morbidity and mortality are significantly improved with targeted therapy.