Eosinophilic esophagitis: Case report and a brief review of the literature

Eosinophilic esophagitis (EoE) is a chronic immune-mediated esophageal disease with symptoms related to esophageal dysfunction and histopathologic features of eosinophil-predominant inflammation. We present the case of a 32-year-old man who was referred for evaluation of a history of 7-month-long progressively worsening solid and subsequently liquid dysphagia. In addition, the patient reported frequent episodes of food impaction, retrosternal chest pain, and proton pump inhibitor-resistant heartburn. The patient had a background of different atopic diseases: he presented with Asthma since childhood, allergic rhinitis, eczema, and food allergies as well.
Physical examination was significant for nasal congestion, eczematous changes, and pulmonary wheezing. Laboratory findings showed a high total IgE, peripheral eosinophilia, and low vitamin B12 and folate levels. Barium esophagram displayed the presence of a ringed esophagus with concentric rings and longitudinal furrows. Endoscopy revealed several characteristics of EoE, such as mucosal rings, furrows, white exudation, and reduced vascularity. The diagnosis was confirmed by histopathologic analysis of several esophageal biopsies in which more than 15 eosinophils per high-power field were seen in more than one field, in addition to basal cell hyperplasia and eosinophilic layering. Therapy was with topical steroids (budesonide viscous slurry) swallowed and a six-food elimination diet, with usual treatment of comorbid atopic conditions. 
Within five weeks, the patient experienced clinical improvement in dysphagia and fewer food impaction episodes. Histologic remission was reached after 10 weeks. Four-year follow-up showed continued remission with no significant complications in the context of a multidisciplinary care plan. The case emphasizes the need to detect EoE early in patients with chronic dysphagia, food impaction, inadequate response to PPI treatment, and atopic history, and the value of a combination of pharmacologic and dietary treatment in a lasting remission.