S4429 Spontaneous Eosinophilic Esophagitis Perforation: A Rare Presentation

Introduction: Eosinophilic esophagitis (EoE) is an immune-mediated disease that causes esophageal dysfunction. We present a case of a spontaneous esophageal perforation in a 24-year-old man who was subsequently diagnosed with EoE. Case Description/Methods: A 24-year-old man presented to our hospital with complaints of chest pain and odynophagia for 1 week. The patient reported chronic solid food dysphagia but no recent history of food impaction or vomiting. He had intermittently been taking pantoprazole, sucralfate, and viscous lidocaine without much improvement. His exam and vitals were unremarkable. His computerized tomography angiogram revealed a 4 cm contained fluid pocket within the mid-esophageal wall. A subsequent Gastrografin® esophagram demonstrated a contained leak in the mid-esophagus. The differential diagnosis was a ruptured duplication cyst versus a contained perforation. Following a multidisciplinary evaluation, he was kept nil by mouth and started on intravenous antibiotics. The patient continued to report odynophagia. He underwent a diagnostic upper endoscopy with fluoroscopy, which revealed a narrow esophageal lumen that could only be traversed with a neonatal XP gastroscope. The endoscopic findings included longitudinal furrows, edema, diffuse exudate, and strictures suggestive of EoE. A deep ulceration with a sinus tract was identified at 30 cm from the incisors. The esophageal biopsies revealed up to 100 eosinophils per high-power field. Stent placement, endovac therapy, and primary closure were considered. However, given the duration of the perforation (>7 days) and clinical stability, the decision was made to maintain a strict nil by mouth diet, total parenteral nutrition, intravenous pantoprazole 40 mg twice daily, intravenous antibiotics, and initiate IM Dupilumab 300 mg once weekly. Steroids were avoided in the setting of a perforation. A computed tomography chest and esophagram, performed 2 weeks later, showed complete resolution of the cavity and no residual leak. The patient clinically improved, and a repeat endoscopy revealed no residual perforation, accompanied by a reduction of EoE features. Discussion: According to our literature review, spontaneous perforation is an infrequent presenting scenario in undiagnosed EoE, as they are typically associated with food impaction-related necrosis or Boerhaave syndrome. Neither were present here. We wish to highlight this rare presentation of EoE and successful management using conservative measures in a condition known to have high morbidity and mortality.