S4303 Not All Rings Are Eosinophilic Esophagitis: Histologic Revelation of Lymphocytic Esophagitis

Introduction: Lymphocytic esophagitis (LE) is a rare inflammatory disorder first described in 2006. The etiology remains unclear—it may represent a unique entity or a manifestation of other diseases. LE more often affects older women and is associated with gastroesophageal reflux disease, smoking, achalasia, hypothyroidism, and medications like aspirin or statins. Symptoms include dysphagia, heartburn, chest discomfort, or food impaction and may also coexist with autoimmune or motility disorders. Endoscopically, findings may mimic eosinophilic esophagitis (EoE), with rings, strictures, or linear furrows; however, the diagnosis of LE requires histologic confirmation. Case Description/Methods: An 89-year-old woman with a history of gastroesophageal reflux disease and chronic obstructive pulmonary disease presented with solid food dysphagia and regurgitation. She reported long-standing symptoms despite daily omeprazole. Esophagogastroduodenoscopy revealed rings, crepe-paper mucosa, and a benign stricture—findings suggestive of EoE. However, histology ultimately revealed a different diagnosis. She underwent dilation and biopsies of the proximal and distal esophagus. Biopsies showed intraepithelial lymphocytosis without granulocytes. Immunostaining confirmed the T-cell predominance characteristic of LE, with CD3+ lymphocytes and minimal CD20+ B-cell involvement. Despite twice a day proton pump inhibitor therapy, dysphagia persisted after 12 weeks, and topical budesonide was initiated. Discussion: LE cannot be reliably distinguished from EoE based on symptoms, demographics, or endoscopic appearance. LE tends to affect older women, while EoE is more common in young men, but both may present with similar clinical features. Histologic examination is essential for diagnosis. LE is characterized by peripapillary lymphocytosis without granulocytes. Though no strict histologic thresholds exist, >20 lymphocytes/HPF is commonly used. The lymphocytes are typically CD3+, often CD4+ or CD8+, with minimal CD20+ B-cell involvement. Treatment begins with proton pump inhibitors; non-responders may need topical steroids. Endoscopic dilation may be required for strictures. No formal LE guidelines exist; treatment often mirrors EoE protocols. This case highlights the diagnostic limitations of endoscopy alone and reinforces the essential role of biopsy in distinguishing LE from EoE to guide appropriate treatment.