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

## TL;DR

This study shows that children with food stuck in the esophagus may have early signs of a condition called eosinophilic esophagitis, even if initial tests don't confirm it.

## Contribution

The study highlights the importance of follow-up testing in children with food impaction to accurately diagnose eosinophilic esophagitis.

## Key findings

- Four pediatric patients with subthreshold eosinophil counts during food impaction later developed confirmed eosinophilic esophagitis.
- Initial biopsy results during food impaction may not reflect true eosinophil levels due to mucosal stress.
- Longitudinal follow-up and repeat endoscopy are essential for accurate diagnosis of eosinophilic esophagitis in these cases.

## 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.

EoE diagnosis is a clinicopathologic diagnosis with symptoms of esophageal dysfunction and ≥15 eosinophilic cells per HPF.Eosinophils are extremely sensitive to their environment and undergo rapid degranulation during times of mucosal stress.Esophageal food bolus impaction is a frequent presenting sign in EoE.

EoE diagnosis is a clinicopathologic diagnosis with symptoms of esophageal dysfunction and ≥15 eosinophilic cells per HPF.

Eosinophils are extremely sensitive to their environment and undergo rapid degranulation during times of mucosal stress.

Esophageal food bolus impaction is a frequent presenting sign in EoE.

A subgroup of patients during esophageal food impactions has been identified with lower than diagnostic thresholds for EoE on eosinophil per HPF count.Repeat mucosal evaluation before empiric treatment, when esophageal mucosa has recovered, can be confirmatory of a diagnosis of EoE.Follow‐up in patients with food impaction, regardless of eosinophil count, is essential.

A subgroup of patients during esophageal food impactions has been identified with lower than diagnostic thresholds for EoE on eosinophil per HPF count.

Repeat mucosal evaluation before empiric treatment, when esophageal mucosa has recovered, can be confirmatory of a diagnosis of EoE.

Follow‐up in patients with food impaction, regardless of eosinophil count, is essential.