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CLINICAL VIGNETTE Eosinophilic EsophagitisRonald S. Siegel, M.D.The presence of abnormal numbers of eosinophils in the stomach, small bowel and colon has been well-described and causes a variety of symptoms termed eosinophilic gastroenteritis. However, this has rarely been reported in the esophagus. A slight increase in esophageal eosinophils (5-10 per high power field) in the distal esophagus is characteristic of reflux esophagitis,1 but large numbers of eosinophils (>20 per high power field) infiltrating the esophagus is distinctly unusual. Recently, a patient was seen with a variety of clinical and endoscopic findings typical of an unusual form of esophagitis illustrated by the following case. Case ReportA 32-year-old male presented to the Emergency Department, complaining of difficulty in swallowing for 24 hours after swallowing a large vitamin pill. He reported a long history of intermittent dysphagia for solids but not liquids, although he never had a prior esophageal obstruction. He denied any history of acid reflux symptoms, or peptic ulcer disease. He had no atopic symptoms, but reported an allergy to peanuts. He was not taking any medications. Family history and review of systems were non-contribu-tory. Physical examination was normal except for the presence of large amounts of saliva in the patient's mouth that he was unable to swallow. An emergency endoscopy was performed, revealing a large pill obstructing the proximal esophagus. The pill was removed endoscopically. Examination of the esophagus revealed no stricture or obstruction. White nodules, 1 to 2 mm in size, were seen scattered along the mucosa, and multiple thin concen-tric mucosal rings were seen extending distally down the esophagus, which appeared narrowed throughout its course. A repeat endoscopy was performed 2 weeks later and biopsies were obtained, which revealed greater than 20 intraepithelial eosinophils per high power field (Figure 1), and multiple eosinophilic microabcesses, both diagnostic of eosinophilic esophagitis. He was treated with topical steroids, consisting of fluticasone, 220 mcg/puff swal-lowed twice daily. His dysphagia resolved over a 4-week period, and has not recurred.  Figure 1. Esophageal biopsy showing marked increase in intraepithelial eosinophils. DiscussionInitially reported in the 1970s,2,3 there were only a few reports of eosinophilic esophagitis until relatively recently, suggesting an accelerating incidence,4 although no large populations studies have been reported in adults. This disorder usually affects men between age 20 and 30 years, although it can be seen in women and can occur at any age.5 Patients typically present with dysphagia (93%), food impaction (62%), and heartburn (34%), while allergic symptoms are reported in 52%, and peripheral eosinophilia in 31%.6 Endoscopic findings are quite typical and include multiple mucosal rings, strictures, linear furrowing, narrowed esophagus, and multiple white papules, although a small percent of patients will have a normal-appearing esophagus.7 Eosinophilic esophagitis can be suspected clinically, but diagnosis requires pathologic confirmation by finding large numbers of intraepithelial eosinophils throughout the esophagus. The etiology of eosinophilic esophagitis is unknown but atopy and eosinophilia are common, suggesting that eosinophilic infiltration of the esoph-agus may be a response to environmental allergens, leading to esophageal inflammation by the release of a variety of interleukins and cytotoxic proteins.8,9 Current approaches to treatment of eosinophilic esophagitis include allergy avoidance and the use of topical steroids in the form of swallowed fluticasone proprionate, an inhaled corticosteroid used in the management of asthma.10 The long-term prognosis for eosinophilic esophagitis is unclear, but in a study of patients followed for an average of 7 years, the majority of patients had persistent dysphagia although the degree of tissue eosinophilia decreased over time, and no cases of dysplasia or neoplasia were observed.11 REFERENCES
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