Interesting Case: when signs and symptoms of aspiration are not what they seem

 

History:

4 year old healthy male with the following presenting symptoms:

 

1. pocketing and holding solid foods in his mouth for prolonged periods of time
2. coughing during and after meal time
3. wet vocal quality toward the middle to end of the meal
4. reduced intake at meal time and some food refusal
5. need for supplement to maintain weight
6. intermittent vomiting
7. effortful swallowing and gulping

 

If I stopped here (and I haven’t told you everything yet), what would your hypothesis be about this child?

 

• Has clinical signs and symptoms of aspiration
• needs a modified barium swallowing study
• may need feeding therapy for weak chewing
• may need referral to GI or ENT

 

This was a return visit for this young man so we had an idea about what was going on and interestingly the primary diagnosis and cause for these symptoms was not oral-pharyngeal. He had presented about a year earlier with the same symptoms with the addition of mild chewing weakness, poor weight gain and frequent vomiting. He was seen by our feeding team and a short course of treatment consisted of the following:

 

• medical treatment for gastroesophageal reflux with initial improvement and a cessation of the vomiting for a short period of time but then it returned
• addition of liquid supplements for weight gain
• oral motor therapy for chewing
• a modified barium swallowing study which he passed without aspiration and normal oral-pharyngeal function

 

Initially, the differential diagnosis for coughing, choking, and wet vocal quality with solids was either poor chewing and swallowing foods whole or a GI issue such as gastroesophageal reflux, dysmotility, or eosinophilic esophagitis. The other significant piece of information was that these symptoms did not appear until the middle of the meal, approximately 10 bites or so into the meal.

 

Parents were hoping to avoid invasive testing and proceeded with medical management, a modified barium swallowing study, and feeding therapy. The patient gained weight, chewing improved and vomiting decreased but did not stop and had periods with more intensity. This patient continued to have coughing and choking during meals to the point where caregivers would only give the child small pieces of cut up food and provided very close supervision with meals.

 

At this point, it was decided that the child needed further diagnostic testing. The child underwent esophagogastroduodenoscopy (EGD) with biopsy, also known as upper endoscopy. Based on the results of the EGD he was diagnosed with EoE (Eosinophilic Esophagitis). Diagnosis is based on the information gained during the scope and biopsies taken during the procedure, “The generally accepted criteria is that the PEAK eosinophil counts of more than 15 to 20 eosinophils seen on a single high powered microscopic field indicates that the diagnosis of eosinophilic esophagitis likely.” from http://www.eosinophilicesophagitishome.org/ This child had greater than 100 eosinophils.

 

Caregivers met with the Gastroenterologist and decided on a course of treatment- diet elimination. The patient went on a strict elimination diet avoiding dairy and soy and then was re-scoped. Results indicated improvement with no eosinophils on biopsy and total elimination of clinical symptoms.

 

At the time we saw the child again, he was undergoing a soy trial with return of clinical symptoms. Caregivers were concerned with the return of oral food holding, coughing and wet vocal quality. A follow up EGD with biopsy revealed over 150 eosinophils.

 

Outcome: The child returned to a strict elimination diet avoiding dairy and soy with improvement in all clinical symptoms. He continues to be followed by the gastroenterologist for on going treatment. No further feeding therapy is needed at this time.