Long-term prognosis and its associated predictive factors in patients with eosinophilic gastroenteritis

BACKGROUND Eosinophilic gastroenteritis(EGE)is a chronic recurrent disease with abnormal eosinophilic infiltration in the gastrointestinal tract.Glucocorticoids remain the most common treatment method.However,disease relapse and glucocorticoid dependence remain notable problems.To date,few studies have illuminated the prognosis of EGE and risk factors for disease relapse.AIM To describe the clinical characteristics of EGE and possible predictive factors for disease relapse based on long-term follow-up.METHODS This was a retrospective cohort study of 55 patients diagnosed with EGE admitted to one medical center between 2013 and 2022.Clinical records were collected and analyzed.Kaplan-Meier curves and log-rank tests were conducted to reveal the risk factors for long-term relapse-free survival(RFS).RESULTS EGE showed a median onset age of 38 years and a slight female predominance(56.4%).The main clinical symptoms were abdominal pain(89.1%),diarrhea(61.8%),nausea(52.7%),distension(49.1%)and vomiting(47.3%).Forty-three(78.2%)patients received glucocorticoid treatment,and compared with patients without glucocorticoid treatments,they were more likely to have elevated serum immunoglobin E(IgE)(86.8%vs 50.0%,P=0.022)and descending duodenal involvement(62.8%vs 27.3%,P=0.046)at diagnosis.With a median follow-up of 67 mo,all patients survived,and 56.4%had at least one relapse.Six variables at baseline might have been associated with the overall RFS rate,including age at diagnosis<40 years[hazard ratio(HR)2.0408,95%confidence interval(CI):1.0082–4.1312,P=0.044],body mass index(BMI)>24 kg/m^(2)(HR 0.3922,95%CI:0.1916-0.8027,P=0.014),disease duration from symptom onset to diagnosis>3.5 mo(HR 2.4725,95%CI:1.220-5.0110,P=0.011),vomiting(HR 3.1259,95%CI:1.5246-6.4093,P=0.001),total serum IgE>300 KU/L at diagnosis(HR 0.2773,95%CI:0.1204-0.6384,P=0.022)and glucocorticoid treatment(HR 6.1434,95%CI:2.8446-13.2676,P=0.003).CONCLUSION In patients with EGE,younger onset age,longer disease course,vomiting and glucocorticoid treatment were risk factors for disease relapse,whereas higher BMI and total IgE level at baseline were protective.

Acute Eosinophilic Pneumonia (AEP) Due to Daptomycin: Is Autoimmunity a Clinico-Pathophysiologic Bridge to AEP?

Daptomycin induced acute eosinophilic pneumonia is a rare and potentially life threatening condition characterized by rapid respiratory failure, pulmonary infiltrates and eosinophilia. Risk factors for acute eosinophilic pneumonia include smoking, environmental irritants or inhalants and certain medications such as Daptomycin [1]. In this review of literature, we aim to explore the potential triggers for developing acute eosinophilic pneumonia in patients exposed to Daptomycin. The exact immune mechanism for daptomycin induced AEP is unknown, however the current proposed mechanism describes a T helper 2 lymphocyte response to inactivated daptomycin in the pulmonary surfactant, which leads to eosinophilia. Disordered T regulatory cell function is seen in patients with certain cancers, allergies and autoimmune conditions. We propose that patients with these underlying risk factors may be at increased risk of developing AEP after becoming exposed to Daptomycin. Understanding potential risk factors is crucial for health care workers as it allows them to identify susceptible populations, explore preventative measures and treat accordingly.

All-trans retinoic acid alleviates transmissible gastroenteritis virus-induced intestinal inflammation and barrier dysfunction in weaned piglets

Background Transmissible gastroenteritis virus(TGEV)is one of the main pathogens causing severe diarrhea of pig-lets.The pathogenesis of TGEV is closely related to intestinal inflammation.All-trans retinoic acid(ATRA)is the main active metabolite of vitamin A,which has immunomodulatory and anti-inflammatory properties.However,it is unclear whether ATRA can alleviate TGEV-induced intestinal inflammation and barrier dysfunction in piglets.This study aimed to investigate the effects of ATRA on growth performance,diarrhea,intestinal inflammation and intesti-nal barrier integrity of TGEV-challenged piglets.Methods In a 19-d study,32 weaned piglets were randomly divided into 4 treatments:Control group(basal diet),TGEV group(basal diet+TGEV challenge),TGEV+ATRA5 group(basal diet+5 mg/d ATRA+TGEV challenge)and TGEV+ATRA15 group(basal diet+15 mg/d ATRA+TGEV challenge).On d 14,piglets were orally administered TGEV or the sterile medium.Results Feeding piglets with 5 and 15 mg/d ATRA alleviated the growth inhibition and diarrhea induced by TGEV(P<0.05).Feeding piglets with 5 and 15 mg/d ATRA also inhibited the increase of serum diamine oxidase(DAO)activ-ity and the decrease of occludin and claudin-1 protein levels in jejunal mucosa induced by TGEV,and maintained intestinal barrier integrity(P<0.05).Meanwhile,5 mg/d ATRA feeding increased the sucrase activity and the expres-sions of nutrient transporter related genes(GLUT2 and SLC7A1)in jejunal mucosa of TGEV-challenged piglets(P<0.05).Furthermore,5 mg/d ATRA feeding attenuated TGEV-induced intestinal inflammatory response by inhibit-ing the release of interleukin(IL)-1β,IL-8 and tumor necrosis factor-α(TNF-α),and promoting the secretion of IL-10 and secretory immunoglobulin A(sIgA)(P<0.05).Feeding 5 mg/d ATRA also down-regulated the expressions of Toll-like receptors and RIG-I like receptors signaling pathway related genes(TLR3,TLR4,RIG-I,MyD88,TRIF and MAVS)and the phosphorylation level of nuclear factor-κB-p65(NF-κB p65),and up-regulated the inhibitor kappa B alpha(IκBα)protein level in jejunal mucosa of TGEV-challenged piglets(P<0.05).Conclusions ATRA alleviated TGEV-induced intestinal barrier damage by inhibiting inflammatory response,thus improving the growth performance and inhibiting diarrhea of piglets.The mechanism was associated with the inhibi-tion of NF-κB signaling pathway mediated by TLR3,TLR4 and RIG-I.

Animal models of eosinophilic esophagitis,review and perspectives

Eosinophilic oesophagitis(EoE)is an allergen/immune-mediated chronic esophageal disease characterized by esophageal mucosal eosinophilic infiltration and esophageal dysfunction.Although the disease was originally attributed to a delayed allergic reaction to allergens and a Th2-type immune response,the exact pathogenesis is complex,and the efficacy of existing treatments is unsatisfactory.Therefore,the study of the pathophysiological process of EOE has received increasing attention.Animal models have been used extensively to study the molecular mechanism of EOE pathogenesis and also provide a preclinical platform for human clinical intervention studies of novel therapeutic agents.To maximize the use of existing animal models of EOE,it is important to understand the advantages or limitations of each modeling approach.This paper systematically describes the selection of experimental animals,types of allergens,and methods of sensitization and excitation during the preparation of animal models of EoE.It also discusses the utility and shortcomings of each model with the aim of providing the latest perspectives on EoE models and leading to better choices of animal models.

Evolving strategies: Enhancements in managing eosinophilic esophagitis in pediatric patients

Eosinophilic esophagitis is a newly recognized disease first described about 50 years ago.The definition,diagnosis,and management have evolved with new published consensus guidelines and newly approved treatment available to pediatricians,enabling a better understanding of this disease and more targeted treatment for patients.We describe the definition,presentation,and diagnosis of eosinophilic esophagitis including management,challenges,and future directions in children.The definition,diagnosis,and management of eosinophilic esophagitis have evolved over the last 50 years.Consensus guidelines and newly approved biologic treatment have enabled pediatricians to better understand this disease and allow for more targeted treatment for patients.We describe the definition,presentation,diagnosis,management,and treatment in addition to the challenges and future directions of eosinophilic esophagitis management in children.

Eosinophilic solid and cystic renal cell carcinoma with aggressive behavior:Two case reports

BACKGROUND Eosinophilic solid and cystic(ESC)renal cell carcinoma(RCC),a unique and emerging subtype of RCC,has an indolent nature;in some rare instances,it may exhibit metastatic potential.Current cases are inadequate to precisely predict the clinical outcome of ESC RCC and determine treatment choices.CASE SUMMARY Herein,we report two patients with ESC RCC.Patient 1 was a young woman with classical pathological characteristics.Patient 2 was a 52-year-old man with multifocal metastases,involving the pulmonary hilar and mediastinal lymph nodes,liver,brain,mesosternum,vertebra,rib,femur,and symphysis pubis.Awareness of ESC RCC,along with its characteristic architecture and immunophenotype,would contribute to making a definitive diagnosis,even on core biopsy samples.CONCLUSION The discovery of ESC RCC molecular signatures may provide new therapeutic strategies in the future.

Fecal microbiota transplantation and prednisone for severe eosinophilic gastroenteritis

Eosinophilic gastroenteritis is a rare disease of unknown etiology. It is characterized by patchy or diffuse eosinophilic infiltration of the bowel wall to a variable depth and various gastrointestinal manifestations. We describe a case of severe eosinophilic gastroenteritis presenting as frequent bowel obstruction and diarrhea in a 35-year-old man. The patient was misdiagnosed and underwent surgery because of intestinal obstruction when he was first admitted to a local hospital. Then he was misdiagnosed as having Crohn&#x02019;s disease in another university teaching hospital. Finally, the patient asked for further treatment from our hospital because of the on-going clinical trial for treating refractory Crohn&#x02019;s disease by fecal microbiota transplantation. Physical examination revealed a slight distended abdomen with diffuse tenderness. Laboratory investigation showed the total number of normal leukocytes with neutrophilia as 90.5%, as well as eosinopenia, monocytopenia and lymphocytopenia. Barium radiography and sigmoidoscopy confirmed inflammatory stenosis of the sigmoid colon. We diagnosed the patient as having eosinophilic gastroenteritis by multi-examinations. The patient was treated by fecal microbiota transplantation combined with oral prednisone, and was free from gastrointestinal symptoms at the time when we reported his disease. This case highlights the importance of awareness of manifestations of a rare disease like eosinophilic gastroenteritis.

Eosinophilic gastroenteritis:An unusual type of gastroenteritis

Eosinophilic gastroenteritis(EGE) is a rare disorder characterized by eosinophilic infiltration of the bowel wall with various gastrointestinal manifestations.Till date only 280 cases have been described in the literature.A high index of suspicion,by excluding other causes of peripheral eosinophilia,is a pre requisite for accurate diagnosis.EGE is an uncommon gastrointestinal disease affecting both children and adults.It was first described by Kaijser in 1937.Presentation may vary depending on location as well as depth and extent of bowel wall involvement and usually runs a chronic relapsing course.This condition can respond to low dose steroid therapy,thereby preventing grave complications like ascites and intestinal obstruction that might need surgical intervention.The natural history of EGE has not been well documented.Eosinophilic gastroenteritis is a chronic,waxing and waning condition.Mild and sporadic symptoms can be managed with reassurance and observation,whereas disabling gastrointestinal(GI) symptom flare-ups can often be controlled with oral corticosteroids.When the disease manifests in infancy and specific food sensitization can be identified,the likelihood of disease remission by late childhood is high.GI obstruction is the most common complication.Fatal outcomes are rare.

Adult eosinophilic gastroenteritis and hypereosinophilic syndromes

Eosinophilic gastroenteritis (EGE) in the adult is a distinctive pathologically-based disorder characterized by an eosinophil-predominant mucosal inflammatory process. Most often,the disorder is detected during endoscopic investigation for abdominal pain or diarrhea. Other causes of gastric and intestinal mucosal eosinophilia require exclusion,including parasitic infections and drug-induced causes. Occasionally,the muscle wall or serosal surface may be involved. EGE appears to be more readily recognized,in large part,due to an evolution in the imaging methods used to evaluate abdominal pain and diarrhea,in particular,endoscopic imaging and mucosal biopsies. Def inition of EGE,however,may be diffi cult,as the normal ranges of eosinophil numbers in normal and abnormal gastric and intestinal mucosa are not well standardized. Also,the eosinophilic inflammatory process may be either patchy or diffuse and the detection of the eosinophilic infiltrates may vary depending on the method of biopsy fixation. Treatment has traditionally focused on resolution of symptoms,and,in some instances,eosinophil quantification in pre-treatment and post-treatment biopsies. Future evaluation and treatment of EGE may depend on precise serological biomarkers to aid in defi nition of the long-term natural history of the disorder and its response to pharmacological or biological forms of therapy.

Diagnosis of eosinophilic gastroenteritis is easily missed

AIM To analyze the clinical characteristics of eosinophilic gastroenteritis(EGE)and to investigate the situations of missed diagnosis of EGE.METHODS First,the clinical characteristics of 20 EGE patients who were treated at our hospital were retrospectively summarized.Second,159 patients who underwent gastroscopy and 211 patients who underwent colonoscopy were enrolled.The pathological diagnosis showed only chronic inflammation in their medical records.The biopsy slides of these patients were reevaluated to determine the number of infiltrating eosinophils in order to assess the probability of a missed diagnosis of EGE.Finally,122 patients who experienced refractory upper gastrointestinal symptoms for at least one month were recruited.At least 6biopsy specimens were obtained by gastroscopy,and the number of eosinophils that had infiltrated was evaluated.Those who met the pathological diagnostic criteria of EGE underwent further examination to confirm the diagnosis of EGE.The probability of a missed diagnosis of EGE was prospectively investigated.RESULTS Among the 20 patients with EGE,mucosal EGE was found in 15 patients,muscular EGE was found in 3patients and serosal EGE was found in 2 patients.Abdominal pain was the most common symptom.The number of peripheral blood eosinophils was elevated in all 20 patients,all of whom were sensitive to corticosteroids.Second,among the 159 patients who underwent gastroscopy,7(4.40%)patients met the criteria for pathological EGE(eosinophil count≥25/HPF).Among the 211 patients who underwent colonoscopy,9(4.27%)patients met the criteria for pathological EGE(eosinophil count≥30/HPF).No patients with eosinophil infiltration were diagnosed with EGE in clinical practice before or after endoscopy.Although these patients did not undergo further examination to exclude other diseases that can also lead to gastrointestinal eosinophil infiltration,these might be the cases where the diagnosis of EGE was missed.Finally,among the 122 patients with refractory upper gastrointestinal symptoms,eosinophil infiltration was seen in 7 patients(5.74%).The diagnosis of EGE was confirmed in all 7 patients after the exclusion of other diseases that can also lead to gastrointestinal eosinophil infiltration.A positive correlation was observed between the duration of the symptoms and the risk of EGE(r=0.18,P<0.01).The patients whose symptoms persisted longer than 6 mo more readily developed EGE.None of the patients were considered to have EGE by their physicians before endoscopy.CONCLUSION Although EGE is a rare inflammatory disorder,it is easily misdiagnosed.When a long history of abdominal symptoms fails to improve after conventional therapy,EGE should be considered.

Eosinophilic gastroenteritis with cytomegalovirus infection in an immunocompetent child

A 3-year-old boy developed transient protein-losing gastroenteropathy associated with cytomegalovirus (CMV) infection. Both IgG and IgM antibodies to CMV were positive in a serologic blood test. Upper gastrointestinal endoscopy showed multiple erosions throughout the body of the stomach, without enlarged gastric folds. Histological examination of the biopsy specimens indicated eosinophilic gastroenteritis and CMV infection. The patient had complete resolution without specific therapy for CMV in four weeks. An allergic reaction as well as CMV infection played important roles in the pathogenesis of this case.

Eosinophilic gastroenteritis presenting as small bowel obstruction: A case report and review of the literature

Eosinophilic gastroenteritis is a rare disease of unknown etiology. It is characterized by eosinophilic infiltration of the bowel wall to a variable depth and symptoms associated with gastrointestinal tract. Recently, the authors experienced a case of eosinophilic gastroenteritis presenting as small bowel obstruction. A 51-year old woman was admitted to our hospital complaining of abdominal pain and vomiting. Physical examination revealed a distended abdomen with diffuse tenderness. Complete blood count showed mild leukocytosis without eosinophilia. Computed tomography confirmed a dilatation of the small intestine with ascites. An emergency laparotomy was performed for a diagnosis of peritonitis due to intestinal obstruction. Segmental resection of the ileum and end to end anastomosis were performed. Histologically, there was a dense infiltration of eosinophils throughout the entire thickness of ileal wall and eosinophilic enteritis was diagnosed. The patient recovered well, and was free from gastrointestinal symptoms at the time when we reported her disease.

Unusual presentations of eosinophilic gastroenteritis:Case series and review of literature

Eosinophilic gastroenteritis (EG) is an uncommon disease characterized by focal or diffuse eosinophilic infiltration of the gastrointestinal tract, and is usually associated with dyspepsia, diarrhea and peripheral eosinophilia. Diffuse gastrointestinal tract and colonic involvement are uncommon. The endoscopic appearance may vary from normal to mucosal nodularity and ulceration. Gastrointestinal obstruction is unusual and is associated with predominantly muscular disease. We present five unusual cases of EG associated with gastric outlet and duodenal obstruction. Two cases presented with acute pancreatitis and one had a history of pancreatitis. Four cases responded well to medical therapy and one had recurrent gastric outlet obstruction that required surgery. Four out of the five cases had endoscopic and histological evidence of esophagitis and two had colitis. Two patients had ascites. These cases reaffirm that EG is a disorder with protean manifestations and may involve the entire gastrointestinal tract. Gastric outlet and/or small bowel obstruction is an important though uncommon presentation of EG. It may also present as esophagitis, gastritis with polypoid lesions, ulcers or erosions, colitis and pancreatitis and may mimic malignancy.

Eosinophilic gastroenteritis associated with eosinophilic cystitis:Computed tomography and magnetic resonance imaging findings

Eosinophilic gastroenteritis(EG) is a rare,distinct clinical entity,and EG associated with eosinophilic cystitis(EC) is extremely rare and has not been well documented.Here,we report two cases of EG and coexistent EC along with findings from computed tomography(CT) and magnetic resonance imaging(MRI).An 18-year-old male with a history of hematuria,urgency and occasional urodynia for two weeks and a 34-year-old male with a history of abdominal distention for one week were admitted to our hospital.Abdominal contrast-enhanced CT in both patients revealed wall thickening in different parts of the gastrointestinal tract with inhomogeneous reinforcement,coexistent with local or diffuse bladder wall thickening with progressive enhancement,and also showed that the bladder mucosal lining was nondestructive.Pelvic MRI showed that the local or diffuse thickened bladder wall was iso-intense on T1-weighted images,hypointense on T2-weighted images,and slightly restricted on diffusion weighted imaging(DWI) in one case.After therapy,the thickened wall of the gastrointestinal tract and urinary bladder had improved markedly in the two cases.To the best of our knowledge,this is the first report on the radiological imaging of EG and coexistent EC by both CT and MRI and the first with DWI findings.

Eosinophilic gastroenteritis:Approach to diagnosis and management

Eosinophilic gastroenteritis (EGE) is a rare and benign inflammatory disorder that predominantly affects the stomach and the small intestine. The disease is divided into three subtypes (mucosal, muscular and serosal) according to klein&rsquo;s classification, and its manifestations are protean, depending on the involved intestinal segments and layers. Hence, accurate diagnosis of EGE poses a significant challenge to clinicians, with evidence of the following three criteria required: Suspicious clinical symptoms, histologic evidence of eosinophilic infiltration in the bowel and exclusion of other pathologies with similar findings. In this review, we designed and applied an algorithm to clarify the steps to follow for diagnosis of EGE in clinical practice. The management of EGE represents another area of debate. Prednisone remains the mainstay of treatment; however the disease is recognized as a chronic disorder and one that most frequently follows a relapsing course that requires maintenance therapy. Since prolonged steroid treatment carries of risk of serious adverse effects, other options with better safety profiles have been proposed; these include budesonide, dietary restrictions and steroid-sparing agents, such as leukotriene inhibitors, azathioprine, anti-histamines and mast-cell stabilizers. Single cases or small case series have been reported in the literature for all of these options, and we provide in this review a summary of these various therapeutic modalities, placing them within the context of our novel algorithm for EGE management according to disease severity upon presentation.

Massive hemorrhagic ascites: A rare presentation of eosinophilic gastroenteritis

According to Klein's classification system, the symp-tomatology of eosinophilic gastroenteritis(EG), a rare disease, differs based on the affected tissue layer. Pati-ents with subserosal EG often have peritoneal effusion. Hemorrhagic ascites due to EG is extremely rare and has not been reported in the literature. Here, we report a 57-year-old woman with EG and massive hemorrhagic ascites. Laboratory investigations showed elevated per-ipheral eosinophils with significant eosinophilia(65.6%). Ultrasonography showed massive abdominal ascites. Ab-dominal paracentesis revealed hemorrhagic peritoneal fluid and microscopy showed predominant eosinophils. Upper gastrointestinal endoscopy revealed erosions, ex-udates, and mucosal rings in the duodenal mucosa; hist-ological examination indicated eosinophilic infiltration. EG presenting with hemorrhagic ascites was diagnosed by histologic examination of eosinophilic infiltration. She was empirically treated with ketotifen 1 mg bid po with rapid resolution of ascites and a remarkable decline in peripheral eosinophil counts. Clinicians should consider the different-ial diagnosis of unexplained hemorrhagic ascites.

Eosinophilic gastroenteritis with abdominal pain and ascites:A case report

BACKGROUND Eosinophilic gastroenteritis(EGE)is a rare disease that presents many unspecific gastroenterological symptoms.The disease includes three types depending on the depth of eosinophil infiltration in the gastrointestinal tract.The serosal type is the most rare,presenting as ascites.CASE SUMMARY A 34-year-old man presented with abdominal pain,diarrhea without bloody stool,or nausea.Laboratory test results revealed a peripheral blood eosinophil count(4.85×10^(9)/L),which was remarkedly elevated.Computed tomography scan demonstrated extensive intestinal wall edema thickening in the duodenum,jejunum,ascending colon and transverse colon;multiple exudative effusion surrounding the intestinal tract,and ascites in the abdominal cavity.A series of examinations excluded eosinophil elevation in secondary diseases.Endoscopic multipoint biopsy detected eosinophilic infiltration in the mucous layer of the transverse colon,with≥50 eosinophils/high power field.All symptoms vanished after a few days of steroid therapy and ascites disappeared within 2 wk.CONCLUSION EGE should be considered in patients with abdominal pain,ascites,and eosinophilia.Multiple point biopsies are essential for diagnosis.

Perforated duodenal ulcer:An unusual manifestation of allergic eosinophilic gastroenteritis

Spontaneous perforation of a duodenal ulcer secondary to allergic eosinophilic gastroenteritis(EGE) has not been previously reported. We present such a case in a teenager who presented with peritonitis. After exploration and operative repair of his ulcer, he continued to experience intermittent abdominal pain, and further evaluation revealed eosinophilic gastroenteritis in the setting of multiple food allergies. His EGE resolved after adhering to a restrictive diet. Both duodenal ulcers and EGE are very rarely seen in pediatric patients. EGE has a variable presentation depending on the layer(s) of bowel wall affected and the segment of the gastrointestinal tract that is involved. Once diagnosed, it may respond to dietary changes in patients with recognized food allergies, or to steroids in patients in whom an underlying cause is not identified. Our case highlights the need to keep EGE in the differential diagnosis when treating pediatric patients with duodenal ulcers. The epidemiology, pathophysiology, and treatment of EGE are also discussed, along with a review of the current literature.

Eosinophilic gastroenteritis with ascites and hepatic dysfunction

Eosinophilic gastroenteritis is a rare gastrointestinal disorder with eosinophilic infiltration of the gastrointestinal wall and various gastrointestinal dysfunctions. Diagnosis requires a high index of suspicion and exclusion of various disorders that are associated with peripheral eosinophilia. We report a case of eosinophilic gastroenteritis, which had features of the predominant subserosal type presenting with ascites and hepatic dysfunction, and which responded to a course of low-dose steroid.

Preliminary evidence in treatment of eosinophilic gastroenteritis in children:A case series

BACKGROUND Eosinophilic gastroenteritis is a rare inflammatory disorder in children.However,there is still no standard guideline in the treatment of pediatric eosinophilic gastroenteritis.AIM To report our experience with the diagnosis and treatment of children with eosinophilic gastroenteritis.METHODS From January 2017 to December 2019,a total of 22 children were diagnosed with eosinophilic gastroenteritis.RESULTS Endoscopic examination showed eosinophil infiltration in the duodenum[mean number of eosinophils/high-power field(HPF)=53.1±81.5],stomach(mean number of eosinophils/HPF=36.8±50.5),and terminal ileum(mean number of eosinophils/HPF=49.0±24.0).All 18 children with low eosinophil infiltration(<14%)responded well to the initial drug treatment without relapse,while two of four children with high eosinophil infiltration(>14%)relapsed after initial methylprednisolone/montelukast treatment.In addition,children with high eosinophil infiltration(>14%)showed symptomatic relief and histological remission without further relapse after receiving budesonide/methylprednisolone as initial or relapse treatment.CONCLUSION Methylprednisolone/montelukast is still the best treatment for children with low eosinophil infiltration(<14%).Budesonide can be considered as the initial or relapse treatment for children with high eosinophil infiltration(>14%).