Successful use of montelukast in eosinophilic gastroenteritis: a case report and a literature review.

BACKGROUND: Eosinophilic gastrointestinal disorders, also known as eosinophilic gastroenteritis, are rare inflammatory conditions characterized by eosinophilic infiltration of different parts of the gastrointestinal tract, along with peripheral eosinophilia in most cases. Other known causes for gut eosinophilic infiltration must be excluded to confirm the diagnosis of eosinophilic gastroenteritis. Symptoms of the disorder depend on the affected gastrointestinal tract segment and depth of involvement. Treatment includes systemic glucocorticoids and/or dietary therapy with an empiric elimination diet. Second line therapies include the leukotriene receptor antagonist montelukast, and other anti-allergy drugs such as mast cell stabilizers (including cromolyn and the H1-antihistamine ketotifen), suplatast tosilate which is a selective Th-2 cytokines (IL-4 and IL-5) inhibitor, and the monoclonal anti-IgE antibody omalizumab. We report a case of eosinophilic gastroenteritis who was successfully treated and achieved remission with montelukast as an initial monotherapy. Upon extensive literature review, this represents the second reported adult case of eosinophilic gastroenteritis who responds to montelukast alone as a first line therapy. CASE PRESENTATION: A 49-year-old female presented with recurrent abdominal pain, vomiting, diarrhea and unexplained eosinophilia. She was diagnosed with eosinophilic gastroenteritis and was successfully treated with montelukast monotherapy. After 7 days of therapy, the patient responded well and had complete resolution of her gastrointestinal symptoms and peripheral eosinophilia. Patient remained in remission on follow-up after 12 months. We reviewed the literature for leukotriene antagonist use in the treatment of eosinophilic gastroenteritis and included the cases treated with the leukotriene antagonist montelukast as an initial therapy or as a second line therapy for refractory disease. CONCLUSION: Montelukast may be an effective treatment for eosinophilic gastroenteritis, either alone or in combination with systemic steroids or ketotifen. Our patient is the second reported adult case of eosinophilic gastroenteritis who responded to montelukast alone as a first line therapy. Further studies and clinical trials are required to confirm efficacy compared to standard therapy.

Improving the diagnostic yield of echocardiography in acute ischemic stroke: A quality improvement project in a community hospital in Maryland, USA.

Background: Echocardiography is routinely ordered in acute ischemic stroke workup. No standardized or structured criteria is used to select or exclude echocardiography in such settings. Moreover, the diagnostic yield of echocardiography in stroke is low in our medical center. This article presents newly proposed selection criteria for echocardiography in ischemic stroke workup. Methods: A quality improvement project was implemented in a 385-bed community hospital in Maryland, USA. A computerized decision support tool consisting of new criteria for selecting echocardiography in ischemic stroke workup was created. 639 patients hospitalized with ischemic stroke were followed-up over 12 months after intervention, and 686 matched-controls with ischemic stroke were retrospectively analyzed from the 12 months prior to intervention. Cost-effectiveness and diagnostic yield of echocardiography in ischemic stroke were measured before and after intervention. Results: Following intervention, the diagnostic yield of echocardiography in ischemic stroke workup significantly increased by 51% (from 3.8% to 7.8%, odds ratio (OR) 2.1, P= 0.01). The number of echocardiography studies needed to detect and treat one patient with a cardiac source of embolism was reduced from 50 to 25 studies. The overall use of echocardiography in stroke workup significantly decreased (OR 0.4, p < 0.001). Patients with lacunar infarcts or atrial fibrillation had significant reduction in echocardiography (OR 0.2, p < 0.001 and OR 0.4, p < 0.001, respectively). Conclusion: The new criteria for echocardiography selection in hospitalized patients with ischemic stroke significantly improved the cost-effectiveness and the diagnostic yield of echocardiography and reduced unnecessary echocardiography in lacunar infarcts or atrial fibrillation.