Case Highlights EoE With Dysphagia Despite No Asthma, Atopic Disease History

Dysphagia is a common symptom of the inflammatory condition eosinophilic esophagitis (EoE), but it is uncommon in people without a history of asthma or atopic conditions.

In a new case report in Cureus, investigators described the case of a 48-year-old man who had long struggled with dysphagia and was eventually diagnosed with EoE, even though he had no history of food or drug allergies, asthma, or atopic conditions. The authors said the case serves as an important reminder that EoE should be considered as a possible cause for dysphagia, even in the absence of other hallmarks of the disease.

The patient in the report sought outpatient care after his dysphagia—which he said had been present for a decade—had steadily worsened over the previous 6 months. The patient did not have a history of reflux disease or esophageal impaction.

A physical examination and vital signs did not reveal any obvious cause to his symptoms, and so the patient was referred for esophagogastroduodenoscopy. The procedure led to an endoscopic reference score of 6, indicative of EoE. Esophageal dilation was performed, and the patient was prescribed a proton pump inhibitor (PPI) based on mild gastritis and the apparent EoE.

He later underwent a biopsy, which revealed 20 eosinophils/high-powered fields, confirming the diagnosis. Three weeks after his office visit, the patient reported that his symptoms had improved, but not resolved. At that point, he was started on fluticasone (Flonase) 440 mcg twice daily. Eight weeks later, the patient reported that his symptoms had resolved. He was advised to continue taking his PPI daily and to take 6-week courses of fluticasone if his symptoms were exacerbated.

The study authors said the current literature suggests that inflammation and fibrostenotic complications of EoE may be the causes of dysphagia in this patient group.

“Our patient's symptom improvement with PPI and corticosteroids suggests that the pain and symptoms were related to an inflammatory process,” they said.

The authors noted that the treatments they used, in addition to the avoidance of dietary triggers, constitutes the typical treatment path for people with EoE. They added, however, that newer therapies such as biologics, montelukast (Singulair), and purine analogs have shown promise as experimental treatments to reduce eosinophil counts.

“Finally, esophageal dilation is an option when pharmacotherapy is inadequate and dysphagia persists,” they said. “Our patient showed symptom improvement from esophageal dilation.”

The investigators noted that the pathophysiology of EoE is complex, and diagnosis of the condition is generally made after ruling out other possible causes.

“Due to the progressive nature and potential outcomes of untreated EoE, we emphasize the importance of prompt clinical diagnosis and appropriate treatment.

In this case, the investigators noted that an extensive immunologic and genetic analysis was not performed. They said such an analysis might have yielded insights into why the patient was predisposed to EoE. Still, they said it was notable that the patient’s symptoms improved even after he had been dealing with them for 10 years.

“The patient's improvement of symptoms accentuates the effectiveness of our treatment regimen given, particularly in the setting of no known atopy,” they said.

Reference

Ward I, Phrathep DD, Healey KD, Anthony S, Herman M. Nonatopic eosinophilic esophagitis in an adult. Cureus. Published online November 28, 2022. doi:10.7759/cureus.31967