Subthreshold eosinophilia during food impaction may mask eosinophilic esophagitis: A pediatric case series.

To describe the clinical scenario and need for longitudinal follow-up of pediatric patients presenting with esophageal food impactions (EFIs) regardless of esophageal biopsy eosinophil count. A retrospective chart review was conducted on patients with EFI who underwent endoscopic evaluation from August 2022 to August 2024. Patients demonstrating eosinophils per high-power field (HPF) between 1 and 14 were identified, and longitudinal assessment evaluated for potential eosinophilic esophagitis (EoE) diagnosis. Four patients presented with EFI and sub-diagnostic eosinophilic counts (1-14 eosinophils/HPF) were assessed longitudinally. In all cases, repeat endoscopy showed an increase in eosinophils, confirming EoE (eosinophils ≥ 15/HPF). EFI is a potential presenting sign of EoE, but initial biopsy results during EFI often show sub-diagnostic eosinophilic counts. Our findings underscore the need for adequate biopsy procurement at the time of EFI, longitudinal follow-up, and repeat endoscopy for accurate EoE diagnosis during EFI.