the past twenty years eosinophilic esophagitis (EoE) has emerged as a leading cause for esophageal symptoms in both children and adults. determine the symptom presentation. Peripheral eosinophilia is a clinical clue to the diagnosis of EoG and is present in most cases. Although the peripheral eosinophil level was not reported in the case study by Benias and colleagues 3 the sensitivity of this test A-769662 for isolated esophageal disease is unknown. In the aforementioned case study a woman age 50 years presented with dysphagia and weight loss and had a narrow-caliber esophagus without apparent mucosal abnormalities on endoscopy.3 The differential diagnosis of the narrow-caliber esophagus includes A-769662 EoE prolonged nasogastric intubation radiation esophagitis caustic injury lichen planus long-segment Barrett esophagus A-769662 bullous cutaneous disorders congenital esophageal stenosis and esophageal intramural pseudodiverticulosis. Neoplastic processes including stromal cell tumors can infiltrate the esophagus in a submucosal manner but typically present with more focal strictures. Over the past A-769662 20 years EoE has emerged as one of the leading causes of the narrow-caliber esophagus.4 A conceptual question regarding this case report is whether the patient has a variant of EoE or an esophageal manifestation of EoG.3 In support of the diagnosis of EoE the eosinophilic inflammation was confined to the esophagus without endoscopic or histologic involvement of the stomach or duodenum.3 The patient however did not have evidence of eosinophilia in the squamous epithelium which is considered a hallmark of EoE.1 Although it is possible that the presence of esophageal mucosal eosinophils could have been suppressed by use of proton pump inhibitors or intermittent use of medications for the patient’s remote history of asthma these are unlikely explanations. As the esophageal eosinophilia in EoE can be patchy multiple (>5) biopsies from different areas of the esophagus have been recommended to maximize detection.5 In this case an unspecified number of biopsies were obtained only at the level of the midesophagus. Specific aspects of this case argue against the diagnosis of EoE but the distinction between EoE and EoG is not well delineated. SLCO2A1 The patient’s clinical presentation with a relatively short duration (4 weeks) of dysphagia and associated weight loss is atypical for EoE. In adults with EoE progressive dysphagia typically manifests over several years prior to diagnosis. Weight loss is uncommon in adults although it is sometimes a feature in children. Endoscopically demonstrable esophageal features including edema rings exudates and furrows are present in the majority of patients but were not noted in this patient.6 The authors suggest that the deeper infiltration of the esophageal submucosa and muscularis supported the diagnosis of EoG rather than EoE. It should be noted however that deeper infiltration of the inflammatory and remodeling processes has been reported in both pediatric and adult presentations of EoE. Deep tissue biopsies have demonstrated eosinophil infiltration of the lamina propria and subepithelial fibrosis in up to 90% of patients with EoE.7 Studies using endoscopic ultrasonography have demonstrated significant thickening of the submucosa as well as muscularis in both children and adults.8 9 Finally case reports of patients undergoing surgical intervention for EoE have demonstrated transmural involvement of eosinophilic inflammation and remodeling.10 Interestingly our group reported a case similar to the one reported by Benias and colleagues.3 Our patient was an elderly man with dysphagia esophageal dysmotil-ity and focal narrowing of the proximal esophagus with normal overlying esophageal mucosa.11 A-769662 Both computed tomography imaging and endoscopic ultrasonography demonstrated marked thickening of the esophageal wall. A fine-needle aspiration of the esophagus demonstrated cellular atypia that resulted in esophageal resection. The pathology of the esophagus demonstrated eosinophilic inflammation of the muscularis propria in the absence of significant mucosal eosinophilia. Similarly among the first case reviews of EoE referred to a man age group 44 years with achalasia.12 The individual was managed having a medical myotomy from the distal esophagus. Operative biopsies proven muscle tissue hypertrophy with intensive eosinophil infiltration. Like the additional 2 instances eosinophilic swelling had not been detected in the esophageal duodenal or gastric mucosa. Co-workers and Benias should A-769662 be.