Eosinophilic Esophagitis and Marked Leukocytosis in Alpha-Gal Syndrome: Infection, Allergy, or Hematologic Malignancy?

Alpha-gal syndrome (AGS) is a tick-borne immunoglobulin E (IgE)-mediated hypersensitivity reaction to galactose-α-1,3-galactose (alpha-gal) found in mammalian meat products. Eosinophilic gastrointestinal disorders (EGIDs), including eosinophilic esophagitis (EoE), are T helper 2 (Th2)-mediated conditions characterized by eosinophilic infiltration of the gastrointestinal tract. We present a case of a 63-year-old man with known AGS who developed dysphagia, rash, pulmonary infiltrates, gastrointestinal eosinophilic infiltrates, and marked eosinophilia. Bone marrow biopsy revealed marked hypercellularity with myeloid predominance and increased eosinophils and eosinophilic precursors. The patient met the diagnostic criteria for idiopathic hypereosinophilic syndrome (HES) based on persistent peripheral eosinophilia, eosinophilic end-organ damage, and exclusion of secondary and clonal causes. This report describes a rare presentation of AGS meeting the symptomatic and diagnostic criteria of EoE alongside a systemic eosinophilic disorder. The possible shared Th2-mediated pathophysiology of these disorders suggests that AGS could act as an immunologic trigger for these disorders, though further research is needed to establish the association.