Case Presentation: A 49-year-old female with a learning disability, asthma, and no smoking history was hospitalized for dysphagia and food bolus impaction. Esophagogastroduodenoscopy revealed esophagitis concerning for eosinophilic esophagitis, and she was discharged with pending biopsies. She returned the following day with lower abdominal pain and worsening shortness of breath. She reported her asthma had been well controlled with intermittent use of Dulera and albuterol, although her mother expressed additional concerns. She lived with several pets, including a rabbit. On presentation, she was afebrile and oxygenating well on room air. Laboratory evaluation showed marked eosinophilia with an absolute eosinophil count of 2,500 cells per microliter, and her respiratory viral panel was positive for non–COVID-19 coronavirus. Chest radiography demonstrated patchy bilateral airspace disease. Computed tomography of the chest revealed multifocal regions of cystic bronchiectasis in both lungs with associated tubular nodules suspicious for mucoid impaction.She was treated initially for viral bronchitis with a possible asthma exacerbation using systemic corticosteroids, inhaled costicosteroids with beta agonist, and nebulized bronchodilators. Due to the significant eosinophilia and abnormal imaging, bronchoscopy with bronchoalveolar lavage was performed and revealed diffuse airway erythema and edema with copious mucopurulent secretions. Further evaluation demonstrated a total IgE of 2,769 IU per milliliter and an Aspergillus fumigatus specific IgE of 20.7 IU per milliliter, confirming allergic bronchopulmonary aspergillosis. She improved on prednisone 40 milligrams daily with plans for a gradual taper and remained stable on room air. She was discharged with outpatient pulmonary follow-up for ongoing management of asthma, ABPA, and biopsy-confirmed eosinophilic esophagitis.

Discussion: This case highlights the rare coexistence of eosinophilic esophagitis and allergic bronchopulmonary aspergillosis, two hypereosinophilic, IgE-mediated disorders, in a patient with asthma. Although asthma commonly accompanies ABPA, its overlap with EoE is unusual and reflects shared Th2-driven pathways involving IL-4, IL-5, and IL-13. For hospitalists, this case emphasizes the importance of considering additional eosinophilic syndromes when one is identified. The incidental detection of ABPA in a patient who reported well-controlled asthma underscores the diagnostic value of cross-sectional imaging for nonspecific or unrelated complaints. Early recognition is essential, as untreated ABPA may lead to progressive bronchiectasis and irreversible lung injury.

Conclusions: This vignette illustrates an uncommon overlap of Th2-mediated eosinophilic diseases and reinforces the need for diagnostic vigilance in hospitalized patients presenting with eosinophilia. Recognizing these associations can support early identification of underdiagnosed conditions such as ABPA, help prevent long-term pulmonary complications, and broaden clinicians’ understanding of hypereosinophilic disease spectrum.

IMAGE 1: Figure 1