November 14, 2026
4 min read
Key takeaways:
- Symptoms associated with food allergy overlap with the indicators of EoE, leading to misdiagnoses.
- EoE incidence has increased since 2009 and it is more common among men and those with multiple comorbidities.
PHOENIX — Often misdiagnosed as food allergy, eosinophilic esophagitis prevalence is rising in the U.S., according to results of two studies presented at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.
Healio previously reported that modifying dietary intake or using medications, such as proton pump inhibitors or dupilumab (Dupixent; Regeneron, Sanofi), can alleviate symptoms associated with EoE. However, without a proper and timely diagnosis, scar tissue can accumulate in and narrow the esophagus, worsening symptoms, according to a press release.
Patients with eosinophilic esophagitis had a mean of 3.24 visits to the ED before being diagnosed after a mean of 5.5 years. Image: Adobe Stock
At ACAAI, Talal Nsouli, MD, FACAAI, FACIP, FAAAAI, clinical professor of pediatrics and allergy-immunology at Georgetown University School of Medicine and medical director of The Watergate and McLean Allergy and Asthma Centers, presented data on cases of delayed diagnoses to help inform future evaluations.
“Routine allergy testing does not diagnose EoE; recognition requires considering the esophagus and obtaining biopsies,” Nsouli told Healio.
Also, Bushra Tbakhi, MD, fellow in allergy/immunology at University of Cincinnati, discussed epidemiological and clinical insights of the condition.
“Improved recognition and earlier diagnosis may help reduce delays in care and improve patient outcomes,” Tbakhi told Healio.
Food allergy or EoE?
Because EoE is triggered by food and involves symptoms that resemble IgE-mediated anaphylaxis, diagnosis can be difficult.
“We saw patients experiencing frightening episodes of throat tightening and difficulty swallowing after eating, repeatedly treated for presumed anaphylaxis,” Nsouli told Healio. “We wanted to understand why these episodes kept recurring and whether an overlooked esophageal disease was the underlying cause.”
Talal Nsouli
Nsouli and colleagues conducted a retrospective review, accessing clinical and allergy history, treatment response and endoscopic and histopathologic data of 29 patients (69% men; mean age, 38.5 years) with EoE that initially had been misdiagnosed as recurrent food-induced anaphylaxis. Common symptoms in the cohort included throat tightening, dysphagia, chest pain, hypersalivation, food impaction and difficulty swallowing.
Although patients with EoE had a mean of 3.24 ± 1.3 visits to the ED and 0.97 ± 0.84 epinephrine administrations, allergy test results did not show IgE-mediated anaphylaxis.
Esophageal biopsies showed 15 or more eosinophils per high-power field, yielding an EoE diagnosis after a mean of 5.55 ± 2.2 years.
“When symptoms begin after eating, food allergy naturally becomes the focus. Throat tightening can overshadow clues such as difficulty swallowing or food getting stuck, and the initial diagnosis may persist across repeated visits,” Nsouli said. “Recurrent food-related swallowing symptoms should prompt consideration of EoE, even when patients already carry a diagnosis of food allergy.”
Nsouli and colleagues noted that a delayed diagnosis presents the risk for fibrostenotic stricture, increasing by 9% per year without treatment.
“Timely endoscopy with biopsies can identify EoE and guide treatment to control inflammation and reduce the risk of esophageal scarring,” Nsouli told Healio. “Our findings support earlier collaboration between allergists and gastroenterologists when food-related episodes involve recurrent swallowing difficulty or food impaction.”
EoE is on the rise
Alongside these findings, Tbakhi and colleagues performed a retrospective analysis using 1990 to 2024 data from the Epic Cosmos database of over 300 million patients to analyze epidemiological and clinical patterns among patients with EoE.
Their analysis included 520,739 patients diagnosed with EoE by diagnostic code alone and 159,279 diagnosed with diagnostic code plus endoscopy and histology.
Bushra Tbakhi
“Compared with more common atopic conditions, EoE has historically been studied in relatively smaller cohorts,” Tbakhi told Healio. “I was also curious about the evolving treatment landscape, particularly the emergence of dupilumab, and wanted to better understand its adoption in real-world clinical practice.”
According to the results, the prevalence of EoE increased by 7.1-fold since 2009, while incidence rates rose by 3.1-fold. Also, a higher proportion of men (59%) had EoE than women, although this trend diminished among older age groups.
Individuals in northern states were more likely to have EoE, such as New Hampshire (0.31%).
“One hypothesis that has been discussed in the literature is the potential influence of vitamin D deficiency and differences in sun exposure related to latitude,” Tbakhi said. “However, we cannot establish a causal relationship from our data.”
Notably, odds ratios for EoE were greater among individuals with multiple allergic comorbidities, such as asthma, allergic rhinitis or eczema (OR = 23.7); gastrointestinal diseases (OR = 11.1); or food allergy (OR = 6.3), especially to wheat (OR = 37.1).
Assessing treatment options, the researchers noted that proton pump inhibitors were most common (83.4%), although dupilumab use increased by 4.4-fold with the FDA approval in 2022.
“One of the most interesting findings was the substantial increase in dupilumab use among patients with EoE, reflecting the evolving treatment landscape and growing role of biologic therapy in managing this disease,” Tbakhi said.
The data suggest importance of considering EoE as a potential aspect of atopic disease, Tbakhi told Healio.
“The strong associations with other allergic conditions highlight the importance of a multidisciplinary approach and maintaining a high index of suspicion, particularly in patients with multiple atopic comorbidities,” she said.
For more information:
Talal Nsouli, MD, FACAAI, FACIP, FAAAI, and Bushra Tbakhi, MD, can be contacted at allergy@healio.com.
Sources/Disclosures
Source:
Press Release
References:
- Nsouli T, et al. When anaphylaxis is not anaphylaxis: Eosinophilic esophagitis mimicking food allergy. Presented at: ACAAI Annual Scientific Meeting; Nov. 12-16, 2026; Phoenix.
- Tbakhi B, et al. Epidemiology and clinical features of eosinophilic esophagitis. Presented at: ACAAI Annual Scientific Meeting; Nov. 12-16, 2026; Phoenix.
Disclosures:
Healio was unable to confirm relevant financial disclosures at the time of publication.
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