S4215 Lymphocytic Esophagitis: Intermittent Dysphagia Masquerading as Untreated Eosinophilic Esophagitis

Introduction: Lymphocytic esophagitis (LyE) is a rare esophageal disorder characterized by esophageal intraepithelial lymphocytosis with minimal granulocyte infiltration and intercellular edema. Endoscopic findings can include erosive esophagitis, concentric rings, strictures, linear furrows, strictures and white plaques. Diagnosis is often confused for eosinophilic esophagitis (EoE) due to similar endoscopic appearance. Case Description/Methods: Eighty-one-year-old woman with rheumatoid arthritis, hiatal hernia, and previously diagnosed EoE presented with intermittent dysphagia and reflux. Patient was diagnosed with EoE in 2022 with no evidence of eosinophilia on biopsy. Esophagogastroduodenoscopy (EGD) noted a small Zenker’s diverticulum with numerous concentric rings and linear furrows consistent with possible EoE. Esophageal biopsies were taken from the proximal and distal esophagus and no dilation offered given higher risk of perforation from previously untreated EoE. Patient was started on a daily proton pump inhibitors. Esophageal biopsy showed benign fragments of squamous mucosa with increased intraepithelial lymphocytes (>20 per high power field) consistent with the actual diagnosis of LyE. Repeat EGD 8 weeks later noted numerous concentric rings and distal esophageal narrowing and biopsy showing acute and chronic inflammation with yeast and fungal forms suggestive of candidal esophagitis; patient was started on budesonide and fluconazole and presented with recurrent candidiasis and resolved lymphocytic esophagitis on follow-up EGD and biopsy. Sprue antibodies were negative. Discussion: LyE is a rare esophageal disorder that can be misdiagnosed as EoE. Diagnostic criteria and treatment are not clearly defined, but on average, patients will present with >10 intraepithelial lymphocytes per high power field, infrequent or absent granulocytes and epithelial damage. Symptomatic treatment has been noted with proton pump inhibitors use, topical steroids such as fluticasone, and esophageal dilation in patients with more prominent esophageal strictures. In addition, immune-mediated diseases such as celiac, Crohn’s disease, and in our patient’s unique case rheumatoid arthritis are increasingly found to be associated with the disease.