5 Both diseases share varying degrees of esophageal eosinophilia and some authors suggest that mucosal injury caused by acid reflux may allow swallowed allergens to penetrate esophageal mucosa causing mild eosinophilia.5 and 7 Gastroesophageal reflux disease is actually the most common cause of eosinophilic infiltration

of the esophagus. However, GERD-related infiltrates tend to be less dense and the greatest number is in the distal esophagus, whereas the dense infiltrates of eosinophilic esophagitis are seen throughout the esophagus.5 and 7 Because of this possible overlap, the diagnosis of eosinophilic esophagitis should be made after acid reflux has been treated or excluded.1 and 5 Before we considered eosinophilic esophagitis

diagnosis and performed esophageal biopsies, our patient tried a trial with pump proton inhibitor at maximum doses VX-809 manufacturer and a pH monitoring excluded pathologic gastroesophageal reflux. Therefore, R428 nmr our patient met all criteria for definitive diagnosis of eosinophilic esophagitis: clinical symptoms, compatible histology and lack of responsiveness to high-dose pump proton inhibitor with normal pH monitoring of the distal esophagus. Because many patients with eosinophilic esophagitis have atopic disease, a complete evaluation for dietary and inhaled allergens by an experienced allergist is recommended. Although we could not find any correlation between our patient’s reflux symptoms and exposition to pollens or grass, avoidance of allergens may be helpful in some patients.1 Large-scale studies in adults have not been conducted. There is no consensus regarding the treatment of eosinophilic esophagitis. In adults, food allergy is less responsible and treatment with topical steroids has lead to remission of symptoms and normalization of hitopathology.1 and 8 Treatment involves spraying Acetophenone and actuation of fluticasone from an inhaler into the mouth and having the patient swallow. Patients should

be instructed to avoid food and liquids for at least 30 minutes after use.1 and 9 A trial of a proton pump inhibitor at maximum doses for at least 8 weeks is also recommended.1 Swallowed fluticasone was very effective in our patient, leading to complete clinical remission after one month of treatment. After six months of treatment, there were no eosinophils in esophageal biopsies. In patients whose symptoms do not improve with fluticasone, several other medications may be tried like systemic corticosteroids, cromolyn sodium and montelukast. A recent open-label trial with mepolizumab, a humanized monoclonal antibody to human interleukin 5, improved clinical symptoms in patients with refractory eosinophilic esophagitis.10 Esophageal stenosis may complicate esophageal esophagitis.