Eosinophilic esophagitis.

Most cases of eosinophilic esophagitis involve young children who present with epigastric pain, regurgitation, and/or vomiting. When it affects adolescents and adults, presenting features are more often dysphagia or food impaction. Male sex, a positive skin-prick or radioallergosorbent test (RAST), and the presence of other atopic diseases are correlated with eosinophilic esophagitis. In most patients, findings on 24-hour pH monitoring are normal. Endoscopic abnormalities--including furrows, vertical lines in the mucosa, rings, adherent whitish plaques, microabscesses, and/or "crepe-paper" mucosa--are very common. Histology is diagnostic when the eosinophil infiltration is greater than 20 eosinophils per high-power field (HPF) in the squamous epithelium. In reflux esophagitis, eosinophilic infiltration is less than 10 eosinophils/HPF.

The etiology of eosinophilic esophagitis is unclear, but it appears that it is the result of an eosinophil-associated inflammation of epithelia, similar to that seen in bronchial asthma and atopic dermatitis. Food antigens and aeroallergens likely play a role in its pathogenesis.

Eosinophilic esophagitis can be treated with inhaled aerosolized steroids, systemic steroids, and leukotriene receptor antagonists, as well as by following an elimination/elemental diet.

We describe 2 cases of eosinophilic esophagitis that were atypical in that they occurred in an adult male and a teenage boy.

Case reports

Patient 1. A 34-year-old man presented with a 4-month history of progressive dysphagia, which was worse with solids than liquids, and a 9-lb weight loss. His medical history included intermittent pyrosis and seasonal allergies. A fiberoptic endoscopic evaluation of his swallowing revealed that the oral and oropharyngeal phases of deglutition were normal. An unsedated transnasal esophagoscopy revealed a corrugated, ringed ("trachealized") esophagus and diminished motility (figure 1). A biopsy of the friable mucosa revealed more than 20 intraepithelial eosinophils/HPF. The patient was treated with a proton-pump inhibitor and oral fluticasone for 6 weeks, and his dysphagia resolved completely.

[FIGURE 1 OMITTED]

Patient 2. A 14-year-old boy with a l-year history of progressive dysphagia with solids complained of an inability to swallow his secretions alter he had eaten a chicken dinner. The patient had a lifelong history of asthma and allergic rhinitis. His father had also experienced several episodes of food impaction of unknown cause, for which he had been treated with esophageal dilation. The patient denied any weight loss or symptoms of gastroesophageal reflux disease or laryngopharyngeal reflux.

Endoscopy demonstrated a diffuse inflammation with linear furrows as well as friable mucosa and linear tears. After the food bolus was removed, biopsies were taken. Histology demonstrated abundant eosinophils (>20/HPF) with bright-red-staining cytoplasm surrounded by norreal-appearing squamous epithelium (figure 2). No other evidence of inflammation was noted. This patient was lost to follow-up.

[FIGURE 2 OMITTED]

Suggested reading

Arora AS, Yamazaki K. Eosinophilic esophagitis: Asthma of the esophagus? Clin Gastroenterol Hepatol 2004:2:523-30.

Liacouras C, Ruchelli E. Eosinophilic esophagitis. Curr Opin Pediatr 2004:16:560-6.

S. Punjab Gupta, MD; Daniel J. Kirse, MD; Gregory N. Postma, MD; Peter C. Belafsky, MD

From the Center for Voice and Swallowing Disorders of Wake Forest University. Winston-Salem, N.C.: www.wfubmc.edu/voice (Dr. Postma. Dr. Gupta, and Dr. Kirse): and the Department of Otolaryngology, University of California, Davis, School of Medicine (Dr. Belafsky).