A Tale of Two “States:” A Penny for Your Thoughts

A 36-year-old female, diagnosed as ulcerative colitis and primary sclerosing cholangitis [Figure 1], was on intermittent mesalamine, prednisolone, and ursodeoxycholic acid since 2013. She presented in 2023 with weight loss, pruritus, bleeding per rectum, and fatigue. She had no history of abdominal pain, fever, or jaundice. Review of previous records showed persistent elevation of serum alkaline phosphatase (159–455 IU/L) and gamma-glutamyl transferase (98–505 IU/L), with normal bilirubin, albumin, and transaminases. Complete blood counts showed leukocytosis (range: 12,600–29,740 Mm3), raised eosinophil count (23%–65%), absolute eosinophil count (624 cells/mm3 to 20,084 cells/mm3), and thrombocytosis (540–819 × 103/µL). Autoimmune workup was positive for ANA 1:100 and perinuclear anti-neutrophil cytoplasmic antibody. Colonoscopy showed mild erythema in the rectum and sigmoid colon. Biopsy showed increased eosinophils in lamina propria (20–30/high-power field) with focal cryptitis and crypt distortion. Bone marrow study showed erythroid suppression and myeloid hyperplasia, with increase in eosinophils and its precursors [Figure 2a and b]. Eosinophilia FISH Leukemia Panel (PDGFRA, PDGGFRB, FGFR1, and CBFB) was negative. Final diagnosis: Idiopathic hypereosinophilic syndrome, eosinophilic colitis, and likelihood of eosinophilic sclerosing cholangitis.[1,2] The patient is currently on steroids, colitis is in remission, eosinophils are normal (3%–4%), and liver biochemistry is normal.Figure 1: MRCP – classical features (large and small duct)Figure 2: (a) Colonic biopsy showing increase of sclerosing cholangitis in eosinophils per high-power field. (b) Bone marrow aspirate showing numerous eosinophilsDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.