“Hard to Swallow”: Dysphagia due to Eosinophilic Esophagitis in Adult Patient with Celiac Disease

Abstract

Purpose: Background: Celiac Disease (CD) and eosinophilic esophagitis (EoE) have been reported concurrently in children and more recently in adults. Common etiological factor underlying both diseases are ingested and/or aero allergens. Management is based on dietary changes and/or topical steroids. Neuropsychiatric CD manifestations present barriers to diagnosis and management. Case: A 27-year-old man diagnosed to have CD, and anxiety disorder was evaluated for worsening dysphagia. Previous duodenal biopsies were consistent with Marsh III CD. He had a 7-year history of dyspepsia and dysphagia to both solids and liquids. He had three food impactions over past 3 years. Upper endoscopies (EGD) for disimpaction were suggestive of EoE and despite recommendations, he was nonadherent to gluten free diet (GFD) and had discontinued PPI therapy as it failed to improve dyspepsia and dysphagia symptoms. Well-chewed foods were easier to swallow, but for past 2 months, he reported choking even with swallowing saliva. He did not report food allergies. Examination was notable for a BMI of 30.4, anxiety, and absence of skin rash. Laboratory data: hemoglobin- 16g/dL, antiendomysial IgA positive, gliadin IGG 11 (<4.9EU/ml), gliadin IGA 1.4 (>6.1 EU/ml), heterozygous DQ8 genotype. Barium swallow was normal except for demonstration of gastro esophageal reflux on valsalva. EGD showed longitudinal furrows and plaques in mid esophagus and edematous duodenal mucosa. Biopsy of esophageal and duodenal mucosa confirmed EoE and CD diagnoses (marked increased esophageal intraepithelial eosinophils, >50 per high power field with degranulation and increased duodenal intraepithelial lymphocytosis, villous atrophy, and crypt hyperplasia with increased mitosis- Marsh III CD). In addition to nutritional counseling for GFD, patient was prescribed oral fluticasone and elimination diet for EoE treatment. He was also compliant with his psychiatric medications. At one-month follow up, dyspepsia was improved, dysphagia completely resolved- no choking spells. DISCUSSION Co-existent CD and EoE has been reported in pediatric literature but there are only few reports in adults. A nine times increased incidence of CD has been reported in children with EoE as compared to the general population. Our case report is unique in that our adult patient had co-existing CD and EoE and in whom the psychiatric co-morbidity initially posed a barrier to GFD adherence.