Recurrent Dysphagia in a 34-year-old Man

A 34-year-old man with a history of asthma is seen in the emergency department 1 hour after getting a bite of steak stuck in his throat. He reports similar episodes of dysphagia in the past that spontaneously resolved after waiting or drinking a glass of water; this time, however, he is concerned that the food is impacted in his esophagus.

On examination he is noticeably uncomfortable and is holding a basin in which to spit his oral secretions. He denies any preceding symptoms of reflux, nausea or vomiting. In order to secure his airway, he is intubated and an upper endoscopy is performed.

Following removal of the impacted food bolus, the esophagus is examined under endoscopy and reveals concentric rings along the entire length of the esophagus. Mucosal biopsies are taken and sent for microscopic evaluation.

What are the likely findings on histopathology from the esophagus?

A. 15 or more eosinophils per high-powered microscopic field (HPF)
B. Positive CD117 immunohistochemical stain
C. Villous blunting
D. Lymphocytic infiltration in the basal layer

Please click here for answer and discussion.

Answer: A. 15 or more eosinophils per high-powered microscopic field

The findings in this clinical vignette are most consistent with eosinophilic esophagitis (EoE). EoE typically presents with symptoms of esophageal dysfunction such as dysphagia, food impaction, heartburn, chest pain, and odynophagia. Patients will often have a history of atopic comorbidities such as asthma, atopic dermatitis, or allergies. The diagnosis of EoE is made based on the above-mentioned symptoms, esophageal biopsies showing ≥15 eosinophils per HPF after excluding other causes of symptoms and esophageal eosinophilia.

In the above choices, a positive CD117 immunohistochemical stain (option B) would be most consistent with a GI stromal tumor (GIST) which does not fit with the clinical scenario. Villous blunting (option C) is seen in the duodenum in the presence of Celiac disease - villi are not present in the esophagus. Lymphocytic infiltration in the basal layer (option D) is seen in lymphocytic esophagitis (LyE), a condition that is clinically similar to EoE, however the demographic representation of LyE is typically older women. Additionally, LyE is not associated with atopic conditions seen in this patient.