A Hard Act to Swallow: The Role of Probe-based Confocal Endomicroscopy in the Diagnosis of Eosinophilic Esophagitis in a Young Man with Dysphagia

Abstract

Purpose: A 19-year old male with a history of GERD was referred to our institution for the evaluation of intermittent dysphagia to solid foods and cold liquids with a reported 20-pound weight loss over the previous 6 months. He denied nausea, vomiting, odynophagia, or any history of food impactions. There were no prior surgeries or significant family history of malignancy or gastrointestinal illness. He reported a ½ pack of cigarette smoking daily for 4 years but denied any alcohol or illicit drug use. Upper endoscopy was performed with the administration of 5 mL of 10% fluorescein IV. A clear cap was attached to the end of the endoscope which was then re-inserted into the esophagus. Probe-based confocal endomicroscopy (Cellvizio, Mauna Kea Technologies, Paris, France) was utilized, which demonstrated increased intracellular spaces, mild mucosal edema, enlarged capillaries with fluorescein leakage, and small eosinophils. These findings during the procedure were consistent with eosinophilic esophagitis. Our in vivo diagnosis was later confirmed by pathology. The distal esophagus was notable for squamous epithelium with basal cell hyperplasia with 50 eosinophils/HPF. The mid-esophagus demonstrated squamous epithelium with 25 eosinophils/HPF and the proximal esophagus showed squamous epithelium with basal cell hyperplasia with 15 eosinophils/HPF. Our patient was discharged home on fluticasone 880 mcg twice daily without a spacer, oral PPI twice daily, and referral to an allergist. At 6-week follow-up the patient reported resolution of dysphagia and improvement of GERD symptoms with subsequent weight gain. This case demonstrates the potential role of endomicroscopy for the in vivo assessment of eosinophilic esophagitis. Future prospective studies on the sensitivity, specificity, and cost effectiveness of this approach are warranted.