A Case of Esophageal Perforation Secondary to Undiagnosed Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disorder of the esophagus, increasingly recognized for its rising prevalence and potential for severe complications. While EoE typically presents with dysphagia, heartburn, and food impaction, it can remain asymptomatic until serious complications such as esophageal perforation occur. This paper highlights a case of a 38-year-old male with a past medical history of occasional gastroesophageal reflux disease (GERD) and reactive airway disease who presented with acute severe chest pain and dyspnea shortly after eating pizza. He was ultimately diagnosed with spontaneous esophageal perforation secondary to previously undiagnosed EoE. Diagnostic imaging revealed a significant mid-esophageal perforation accompanied by pneumomediastinum. Esophagogastroduodenoscopy (EGD) revealed a large esophageal perforation with a dilated esophagus and mucosal linear furrows, which were biopsied. Histopathological examination of the biopsies revealed an eosinophil count of up to 52 eosinophils per high-power field in the mid-esophagus. The patient's management required multidisciplinary intervention, including endoscopic and surgical repair, endoluminal vacuum-assisted closure, and prolonged antimicrobial and nutritional support. These measures ultimately led to complete recovery without further complications. This case emphasizes the potential severity of undiagnosed EoE and highlights the importance of early diagnosis and intervention. Practitioners should maintain a high index of suspicion for EoE in patients with GERD or atypical esophageal symptoms to prevent potentially life-threatening outcomes.