Subthreshold eosinophilia during food impaction may mask eosinophilic esophagitis: A pediatric case series

Abstract

To describe the clinical scenario and need for longitudinal follow-up of pediatric patients presenting with esophageal food impactions (EFIs) regardless of esophageal biopsy eosinophil count. A retrospective chart review was conducted on patients with EFI who underwent endoscopic evaluation from August 2022 to August 2024. Patients demonstrating eosinophils per high-power field (HPF) between 1 and 14 were identified, and longitudinal assessment evaluated for potential eosinophilic esophagitis (EoE) diagnosis. Four patients presented with EFI and sub-diagnostic eosinophilic counts (1-14 eosinophils/HPF) were assessed longitudinally. In all cases, repeat endoscopy showed an increase in eosinophils, confirming EoE (eosinophils ≥ 15/HPF). EFI is a potential presenting sign of EoE, but initial biopsy results during EFI often show sub-diagnostic eosinophilic counts. Our findings underscore the need for adequate biopsy procurement at the time of EFI, longitudinal follow-up, and repeat endoscopy for accurate EoE diagnosis during EFI.

Keywords: atopic; degranulated; dysphagia; esophagus; mucosa.

Figure 1

Endoscopic gross findings of esophagitis noted for patients (A–D), an index esophageal food impaction. Patient (A) demonstrates exudates, edema, and deep furrows. Patient (B) with edema and furrows. Patient (C) with edema and furrows, and Patient (D) with edema, furrows, and subtle rings.