A Case of Two Brothers With Dysphagia Due to Eosinophilic Esophagitis

Abstract

Eosinophilic esophagitis (EoE) is a disease that is still not fully understood. Its pathogenesis, while increasingly clarified, still remains highly complex, which means that no curative treatment has been defined for this clinical entity. It is clear that it is a disease of multifactorial etiology, in which both genetics and environmental factors, especially those related to childhood, have considerable weight, and there is an important allergenic factor as well. We present the case of two brothers with EoE. Two male patients aged 20 and 22 years, white, with a personal history of atopy, allergic rhinitis, and dermatitis, consulted the gastroenterologist for dysphagia. Endoscopy and esophageal biopsy showed elements compatible with EoE in both of them. Treatment was conducted with proton pump inhibitor (PPI) monotherapy in one of the brothers, and PPI with oral steroid in the other, both of which led to good results in terms of symptoms. In the first case, histologic evidence of the disease persisted despite the symptomatic resolution; the second did not pursue a follow-up. The biggest questions pertaining to the treatment of this condition are as follows: Is suppression of gastric acidity enough? Should we use steroids? How about a combination of both? Should we adopt new therapies? New studies involving randomized trials should be conducted to address these questions in order to treat each patient individually with an effective and practical approach that is also supported by the literature.

Keywords: atopy; biopsy; endoscopy; eosinophilic esophagitis; gastroenterology; genetics.

Figure 1. First endoscopy of patient 1

The images show focal exudates (1A), multiple whitish punctate lesions throughout the esophagus (1B, G), mucosal involvement with signs suggestive of loss of vascularization (1A-G), and esophageal grooves and rings (1C-D)

Figure 2. First biopsy of patient 1

The images show evidence of squamous epithelium with spongiosis, reactive changes, and the presence of intraepithelial eosinophils with microabscess formation, counting up to 43 eosinophils per high magnification field (2A-F). Chronic gastritis without activity is observed (2G-I)

Figure 3. Second endoscopy of patient 1

Focal exudates (3A-C), the persistence of rings and grooves (3B, D, H), edema (3E-G), and focal erythema (3D) are evident

Figure 4. Second biopsy of patient 1

Severe inflammation (4D-L), eosinophilic infiltrates (4D-L), high magnification field count of more than 60 eosinophils in distal esophagus (4D-F), 23 eosinophils in the middle esophagus (4G-I), and 30 in the proximal esophagus (4J-L), and edema and congestion are also observed. Lymphocytes are also found in the middle esophagus (4G-I)

Figure 5. Endoscopy of patient 2

The images show linear lesions smaller than 5 mm (Grade A) (5F), whitish-yellowish exudates throughout the organ that were easily detached (5B, C, D, F, H-J), and focal areas of inflammation (5A, E, G, H)

Figure 6. Biopsy of patient 2

The images show severe inflammation of the esophagus, eosinophilic infiltrates, high magnification field count of more than 20 eosinophils per high power field, scarce Candida pseudohyphae (6D-I); and in the stomach, moderate inflammation, with infiltrates of macrophages, lymphocytes, and plasmocytes, and Helicobacter pylori in moderate amount (6A-C)