(previously cited as an image of the month, Cohen et al)
A 56-year-old Caucasian male with a history of asthma, seasonal allergies, and occasional heartburn presented with nausea and vomiting followed by chest and epigastric pain. Computed tomographic (CT) scan revealed air and fluid surrounding the esophagus from the level of the bronchial bifurcation through the gastro-esophageal junction (GEJ), consistent with esophageal rupture complicated by pneumomediastinum and medastinitis. Patient was taken to the operating room and underwent primary repair of a 5-cm perforation located 3-cm proximal to the GEJ. Postoperative course was complicated by 3 months of continuous drainage from the site of rupture requiring mediastinal lavage and bilateral chest tubes. At 9-month follow up, the patient reported symptoms of heartburn, regurgitation and dysphagia to solid foods. Esophagoscopy revealed a characteristic feline appearance and biopsy showed intact squamous mucosa with a diffuse intraepithelial eosinophilic infiltrate exceeding 30 eosinophils per hpf, consistent with EoE. The patient was treated medically with a proton pump inhibitor and oral fluticasone.