CLINICAL COMMUNICATION TO THE EDITOR
Recurrent Back Pain of Eosinophilic Esophagitis To the Editor: A 66-year-old man presented with 5 episodes per week of recurrent severe back pain for 2 weeks. At an emergency clinic, laboratory tests, electrocardiography, contrastenhanced thoracoabdominal computed tomography, and upper gastrointestinal endoscopy had revealed nothing remarkable. His history included aspirin-induced asthma, hypertension, and hyperlipidemia. Current medications were oral candesartan, amlodipine, and simvastatin, as well as inhaled beclomethasone dipropionate. He complained of spontaneous midline back pain at Th 4-7 that worsened over 30 minutes and resolved after 2 hours. It was not aggravated by movement, suggesting referred visceral pain. The pattern of pain and the test results excluded angina pectoris, gallstones, chronic pancreatitis, and peptic ulcer, while the duration, repeatability, and site of pain suggested esophageal spasm. Review of the computed tomography revealed mid to distal esophageal wall thickening (Figure). Endoscopy performed at our hospital identified slight linear furrows at this site, while biopsy revealed epithelial infiltration of eosinophils (15 per high power field) in all 4 specimens. The eosinophil count was 605/mL, with no organopathy to suggest hypereosinophilic syndrome. Among diseases associated with eosinophilic infiltration of the esophagus, eosinophilic gastroenteritis and Crohn disease were excluded in this patient, because upper and lower gastrointestinal endoscopy with random biopsy at a total of 10 sites identified no abnormalities outside the esophagus. Pathological examination showed no evidence of esophageal infection, and his symptoms did not suggest celiac disease or vasculitis.
Funding: None. Conflict of Interest: None. Authorship: All authors have had access to the data and have contributed to writing this manuscript and accept responsibility for the scientific content of the manuscript. Requests for reprints should be addressed to Takeshi Kondo, MD, Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba 260-8677, Japan. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
Because symptoms persisted despite 3 weeks of treatment with esomeprazole (20 mg/day), prednisolone (30 mg/day) was started. Painful attacks subsided completely after 2 days, confirming the diagnosis of esophageal spasm attributable to eosinophilic esophagitis. After 6 months from the start of treatment, symptoms have not recurred and prednisolone has been tapered to 7 mg/day. Eosinophilic esophagitis is a chronic inflammatory disease featuring eosinophilic infiltration of the esophageal mucosa/submucosa that resembles asthma with regard to childhood onset, the role of allergy, and responsiveness to steroids. It typically affects young men, presenting with intermittent dysphagia and chest pain that progress to persistent dysphagia. It is often associated with food allergy or allergic skin/airway diseases. Peripheral blood eosinophilia is found in
Recurrent Back Pain of Eosinophilic Esophagitis To the Editor: A 66-year-old man presented with 5 episodes per week of recurrent severe back pain for 2 weeks. At an emergency clinic, laboratory tests, electrocardiography, contrastenhanced thoracoabdominal computed tomography, and upper gastrointestinal endoscopy had revealed nothing remarkable. His history included aspirin-induced asthma, hypertension, and hyperlipidemia. Current medications were oral candesartan, amlodipine, and simvastatin, as well as inhaled beclomethasone dipropionate. He complained of spontaneous midline back pain at Th 4-7 that worsened over 30 minutes and resolved after 2 hours. It was not aggravated by movement, suggesting referred visceral pain. The pattern of pain and the test results excluded angina pectoris, gallstones, chronic pancreatitis, and peptic ulcer, while the duration, repeatability, and site of pain suggested esophageal spasm. Review of the computed tomography revealed mid to distal esophageal wall thickening (Figure). Endoscopy performed at our hospital identified slight linear furrows at this site, while biopsy revealed epithelial infiltration of eosinophils (15 per high power field) in all 4 specimens. The eosinophil count was 605/mL, with no organopathy to suggest hypereosinophilic syndrome. Among diseases associated with eosinophilic infiltration of the esophagus, eosinophilic gastroenteritis and Crohn disease were excluded in this patient, because upper and lower gastrointestinal endoscopy with random biopsy at a total of 10 sites identified no abnormalities outside the esophagus. Pathological examination showed no evidence of esophageal infection, and his symptoms did not suggest celiac disease or vasculitis.
Funding: None. Conflict of Interest: None. Authorship: All authors have had access to the data and have contributed to writing this manuscript and accept responsibility for the scientific content of the manuscript. Requests for reprints should be addressed to Takeshi Kondo, MD, Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba 260-8677, Japan. E-mail address: [email protected]
0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
Because symptoms persisted despite 3 weeks of treatment with esomeprazole (20 mg/day), prednisolone (30 mg/day) was started. Painful attacks subsided completely after 2 days, confirming the diagnosis of esophageal spasm attributable to eosinophilic esophagitis. After 6 months from the start of treatment, symptoms have not recurred and prednisolone has been tapered to 7 mg/day. Eosinophilic esophagitis is a chronic inflammatory disease featuring eosinophilic infiltration of the esophageal mucosa/submucosa that resembles asthma with regard to childhood onset, the role of allergy, and responsiveness to steroids. It typically affects young men, presenting with intermittent dysphagia and chest pain that progress to persistent dysphagia. It is often associated with food allergy or allergic skin/airway diseases. Peripheral blood eosinophilia is found in
