Defer No Time, Delays Have Dangerous Ends (William Shakespeare)

Abstract

Question: A 22-year-old man was diagnosed with eosinophilic esophagitis (EoE) at the age of 9 years in 2007. Already on initial endoscopic presentation, severe stricture formation was described requiring bougie dilation (3 sessions within the first 6 months). Subsequently, treatment with swallowed topical steroids was initiated. After having achieved clinical remission, the patient stopped therapy after 6 months. However, 2 months after withdrawal of steroids, the patient developed a clinical, endoscopic, and histological relapse. Subsequently, the patient was lost to further follow-up, engaging in a sporadic, symptom-guided, and self-directed topical steroid treatment. After almost 10 years without any endoscopic assessment of the disease state, the last endoscopic follow-up antecedent to the current presentation 1 year ago revealed active EoE with edema, furrows, and white exudates (Figure A), with long stricture formation in the mid and distal esophagus. The latter precluded passage with a standard gastroscope (outer diameter 9.9 mm), requiring guidewire placement for subsequent dilation to 9 mm using a nasal endoscope (large mucosal tear; Figure B). Histology revealed typical EoE characteristics, including eosinophilic abscesses (arrow: proximal esophagus; Figure C). Subsequently topical