Notwithstanding, biopsies were obtained from the proximal and distal esophagus. Histological examination revealed more than 20 intraepithelial eosinophils per high power field and multiple eosinophilic microabcesses (Fig. Nutlin-3 manufacturer 3), both diagnostic of eosinophilic esophagitis. Biopsies from stomach and duodenum were also obtained and histological findings were normal. The patient was treated with a fluticasone inhaler (four 200 μg puffs twice daily), with instructions to swallow and to rinse her mouth. She also continued treatment with pump-inhibitor (omeprazol

40 mg/day). During the next 6 months, her symptoms improved. An endoscopy was then carried out and new biopsies from middle and distal esophagus were taken. No eosinophils were found in the biopsy specimen. Increased number of eosinophils in the gastrointestinal tract has been described in a variety of diseases including Crohn’s disease, connective tissue disorders, malignancy and hypersensivity reactions.1 However, not until 1993 was eosinophilic esophagitis described as a clinical entity.3 The pathologic mechanisms of eosinophilic esophagitis are unknown, but emerging evidence suggests that, like many other allergic diseases, it is mediated by a type 2 T helper cell immune response. Actually, up to 80% of patients with eosinophilic esophagitis

have a history of atopic disease such as asthma, allergic rhinitis, eczema or allergies to food.1 Peripheral eosinophilia is seen in 31% of patients.4 Our patient showed increased blood eosinophils but the serum IgE level was normal and she had a history learn more of bronchial asthma. Clinical presentations of this newly

recognized disease include dysphagia (93%), food impaction (62%), atypical chest pain and heartburn (34%)4 that does not respond to standard medical Phospholipase D1 treatment. Careful endoscopic examination may reveal ringed appearance, subtle furrows, whitish plaques, fragile crêpe paper-like appearance and a small-caliber esophagus. Between 9% and 32% of patients with symptoms have normal endoscopic findings. 1 Barium radiography may demonstrate concentric rings or strictures and should be performed before esophageal dilatation. Esophageal manometry is of limited diagnostic value and so is not recommended as a routine test.1 Marked eosinophil infiltration in the esophageal epithelia (>20 eosinophils per high-power field) is the diagnostic hallmark and samples should be obtained from proximal and distal esophagus,1, 2, 3 and 4 even in normal appearing mucosa in endoscopy.5 In our case report, we found normal appearing mucosa at endoscopy, but esophageal biopsies revealed marked eosinophilic infiltration. Recently, a prospective study conducted by Prasad G. et al. concluded that midesophageal biopsies taken from normal-appearing mucosa in patients with unexplained solid food dysphagia may diagnose eosinophilic esophagitis in about one in 10 cases.