eosinophilic cystitis and parasitic infection

"Introduction
Eosinophilic cystitis is a rare condition characterized by eosinophilic inflammation of the bladder with few documented pediatric cases. The mechanism of disease remains unclear, although it has been associated with various disorders such as allergic diseases, malignancy, trauma, and infection. Treatment regimens are non-standardized and have included antihistamines, leukotriene antagonists, antimicrobials, steroids, and anti-inflammatory agents.

Case Description
A 12-year-old African American male with history of food allergy and allergic rhinitis presented to urology due to persistent hematuria and dysuria. Cystouretheroscopy with biopsy demonstrated evidence of eosinophilic cystitis. He denied use of any medications or history of international travel. CBC revealed a normal AEC of 388 cells/µL; however, he was noted to have eosinophilia to 1670 cells/µL on CBC performed four years prior. He was initially treated with phenazopyridine, oxybutynin, and cetirizine. Montelukast and ibuprofen were added for refractory symptoms. Due to consideration for immunosuppressive steroid therapy, stool O&P, Strongyloides, Trichinella, Toxocara serologies, and GI PCR panel were sent to exclude parasitic infection. Strongyloides IgG and Clostridium difficile toxin were positive. He was treated with ivermectin and metronidazole for latent Strongyloides infection and C. difficile colitis, respectively, and demonstrated interval clinical improvement.

Discussion
To the authors’ knowledge, this is the first case of eosinophilic cystitis associated with Strongyloides stercoralis infection. A high index of suspicion for parasitic infection in patients with eosinophilic cystitis must be maintained regardless of exposure history or peripheral eosinophil counts as chronic infection may be asymptomatic. Initiation of steroid therapy without confirming negative testing may result in life-threatening, disseminated strongyloidiasis."

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