Manuscript Title: Bronchoalveolar lavage eosinophilia and pulmonary symptoms in pediatric eosinophilic esophagitis. Author Information

Manuscript Title: Bronchoalveolar lavage eosinophilia and pulmonary symptoms in pediatric eosinophilic esophagitis. Author Information | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 18 September 2025 V1 Latest version Share on Manuscript Title: Bronchoalveolar lavage eosinophilia and pulmonary symptoms in pediatric eosinophilic esophagitis. Author Information Authors : Yadira M. Rivera Sánchez 0000-0003-0625-4741 [email protected] , Yutika Mandal , Princy Ghera , Stephen Chorney 0000-0003-1419-6019 , Akaash Goyal , John Bird 0000-0003-3772-6078 , Christopher Parrish , and Michael Dang Authors Info & Affiliations https://doi.org/10.22541/au.175821353.34231012/v1 218 views 178 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: Bronchoalveolar lavage (BAL) is often utilized to evaluate lower airway inflammation in children with complex pulmonary conditions. The implications of eosinophilia in BAL are understudied, and thus, its finding is often underutilized diagnostically. In particular, the role of BAL in pediatric eosinophilic esophagitis (EoE) has not been thoroughly explored. Objective: To assess the presence of bronchoalveolar lavage (BAL) eosinophilia and respiratory symptoms in pediatric patients with eosinophilic esophagitis (EoE). Study and Methods : A retrospective chart review included patients aged ≤18 years who underwent simultaneous esophagogastroduodenoscopy (EGD) and flexible bronchoscopy with BAL at a tertiary pediatric hospital between 2013 and 2023. Patients with biopsy-confirmed EoE were compared to those requiring these procedures for other conditions (grouped as the control arm of the study). BAL eosinophilia was defined as >1% of the total cell count. Demographic, clinical, and laboratory data were extracted and analyzed. Results: A total of 132 patients were reviewed, and 103 (45 with EoE and 58 controls) were analyzed. Control group diagnoses included bronchopulmonary dysplasia (N=24, 41%), cystic fibrosis (N=23, 40%), and primary ciliary dyskinesia (N=11,19%). BAL eosinophilia was significantly more common in the EoE group (36% vs. 10%, P =.002). Among EoE patients, chronic cough was as prevalent as gastroesophageal reflux symptoms. The presence of other atopic conditions or infection did not correlate significantly with BAL eosinophilia. Conclusion: BAL eosinophilia is significantly more prevalent in pediatric patients with EoE compared to those with other pulmonary conditions. These findings support the inclusion of EoE in the differential diagnosis of chronic cough and BAL eosinophilia in pediatric patients. Prospective studies are needed to validate these findings and refine diagnostic approaches. Manuscript Title: Bronchoalveolar lavage eosinophilia and pulmonary symptoms in pediatric eosinophilic esophagitis. Author Information Yutika Mandal, MD (first author) University of Texas Southwestern Medical Center Department of Pediatrics Division of Pediatric Pulmonology and Sleep, Children’s Medical Center Dallas, 2350 North Stemmons Freeway, Dallas, TX 75207, USA Department of Pediatric Pulmonology and Sleep, Children’s Medical Center Dallas, Dallas, TX, USA. [email protected] Stephen Chorney, MD, MPH University of Texas Southwestern Medical Center Department of Otorhinolaryngology Division of Pediatric Otolaryngology, Children’s Medical Center Dallas, 2350 North Stemmons Freeway, Dallas, TX 75207, USA; Children’s Health Airway Management Program, Department of Pediatric Otolaryngology, Children’s Medical Center Dallas, Dallas, TX, USA. [email protected] J. Andrew Bird, MD University of Texas Southwestern Medical Center Department of Pediatrics Division of Allergy and Immunology, Children’s Medical Center Dallas, 2350 North Stemmons Freeway, Dallas, TX 75207, USA Department of Allergy and Immunology, Children’s Medical Center Dallas, Dallas, TX, USA. [email protected] Michael Dang, MSDS Department of Population and Data Sciences (Biostatistics), University of Texas Southwestern Medical Center, Dallas, Texas, USA [email protected] Princy Ghera, MD University of Texas Southwestern Medical Center Department of Pediatrics Division of Pediatric Pulmonology and Sleep, Children’s Medical Center Dallas, 2350 North Stemmons Freeway, Dallas, TX 75207, USA Department of Pediatric Pulmonology and Sleep, Children’s Medical Center Dallas, Dallas, TX, USA. [email protected] Aakash Goyal, MD University of Texas Southwestern Medical Center Department of Pediatrics Division of Gastroenterology, Children’s Medical Center Dallas, 2350 North Stemmons Freeway, Dallas, TX 75207, USA Department of Gastroenterology, Children’s Medical Center Dallas, Dallas, TX, USA. [email protected] Christopher Parrish, MD University of Texas Southwestern Medical Center Department of Pediatrics Division of Allergy and Immunology, Children’s Medical Center Dallas, 2350 North Stemmons Freeway, Dallas, TX 75207, USA Department of Allergy and Immunology, Children’s Medical Center Dallas, Dallas, TX, USA. [email protected] Yadira Rivera Sánchez, MD (corresponding author) Mailing Address: 2350 North Stemmons Freeway, Dallas, TX 75207, USA Department of Pediatric Pulmonology and Sleep, Children’s Medical Center Dallas, Dallas, TX, USA. Fax: 214-456-5406 Tel: 214-456-2857/972-804-4461 Email: [email protected] Conflicts of Interest Statement: Conflicts of Interest: None Funding Statement: Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award Number UL1 TR003163. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH (National Institutes of Health). Keywords : eosinophilic esophagitis, eosinophilia, bronchoalveolar lavage Abbreviations: BAL (bronchoalveolar lavage); EoE (eosinophilic esophagitis); CF (cystic fibrosis); PCD (primary ciliary dyskinesia); BPD (bronchopulmonary dysplasia); DRESS (drug reaction with eosinophilia and systemic syndrome); FeNO (fractional exhaled nitric oxide); IgE(immunoglobulin E); DLB (direct laryngobronchoscopy); LLM (lipid-laden macrophages); SUA (severe uncontrolled asthma); CBC (complete blood count) Word Count: 2,805 Number of Figures and Tables: 5 Bronchoalveolar lavage eosinophilia and pulmonary symptoms in pediatric eosinophilic esophagitis. Abstract: Background: Bronchoalveolar lavage (BAL) is often utilized to evaluate lower airway inflammation in children with complex pulmonary conditions. The implications of eosinophilia in BAL are understudied, and thus, its finding is often underutilized diagnostically. In particular, the role of BAL in pediatric eosinophilic esophagitis (EoE) has not been thoroughly explored. Objective: To assess the presence of bronchoalveolar lavage (BAL) eosinophilia and respiratory symptoms in pediatric patients with eosinophilic esophagitis (EoE). Study and Methods : A retrospective chart review included patients aged ≤18 years who underwent simultaneous esophagogastroduodenoscopy (EGD) and flexible bronchoscopy with BAL at a tertiary pediatric hospital between 2013 and 2023. Patients with biopsy-confirmed EoE were compared to those requiring these procedures for other conditions (grouped as the control arm of the study). BAL eosinophilia was defined as >1% of the total cell count. Demographic, clinical, and laboratory data were extracted and analyzed. Results: A total of 132 patients were reviewed, and 103 (45 with EoE and 58 controls) were analyzed. Control group diagnoses included bronchopulmonary dysplasia (N=24, 41%), cystic fibrosis (N=23, 40%), and primary ciliary dyskinesia (N=11,19%). BAL eosinophilia was significantly more common in the EoE group (36% vs. 10%, P =.002). Among EoE patients, chronic cough was as prevalent as gastroesophageal reflux symptoms. The presence of other atopic conditions or infection did not correlate significantly with BAL eosinophilia. Conclusion: BAL eosinophilia is significantly more prevalent in pediatric patients with EoE compared to those with other pulmonary conditions. These findings support the inclusion of EoE in the differential diagnosis of chronic cough and BAL eosinophilia in pediatric patients. Prospective studies are needed to validate these findings and refine diagnostic approaches. Keywords: eosinophilic esophagitis, eosinophilia, bronchoalveolar lavage Background Bronchoalveolar lavage (BAL) is often utilized to evaluate lower airway inflammation in children with complex pulmonary conditions. The implications of eosinophilia in a BAL are understudied, and thus, its finding is often underutilized diagnostically. In particular, the role of BAL in pediatric eosinophilic esophagitis (EoE) has not been thoroughly explored. Eosinophilic esophagitis (EoE) is an immune-mediated inflammatory condition of the esophagus, characterized histologically by eosinophilic inflammation. The pathophysiology of EoE involves a T2 immune response to food and environmental allergens [1]. It is often associated with other atopic conditions, including asthma, allergic rhinitis, and eczema. The presenting symptoms of esophageal dysfunction in EoE are nonspecific and can vary with age [2]. Gastrointestinal manifestations of EoE, such as dysphagia, regurgitation, vomiting, food impaction, and failure to thrive, have been well-described [3]. However, much less is known about the extra-esophageal symptoms of EoE. There is increasing evidence to suggest that EoE may also contribute to pulmonary complications such as chronic cough or difficult-to-control asthma [4]. For example, a study at one aerodigestive clinic found that 6% of pediatric patients who presented with persistent pulmonary symptoms were ultimately diagnosed with EoE [5]. Recognizing the potential for pulmonary manifestations of EoE and improving timely detection can have a significant impact on patient outcomes. Given the immunologic overlap between EoE and other eosinophilic or atopic airway diseases, we hypothesize that BAL eosinophilia may be more prevalent in children with EoE compared to controls with pulmonary conditions. Since pulmonary manifestations are common in EoE, these patients contribute significantly to the cohort of patients undergoing BAL, and we wanted to study whether the presence of eosinophilia in the BAL results could be associated with a diagnosis of EoE. To our knowledge, this is the first pediatric study to examine BAL eosinophilia and its associated factors in pediatric patients with EoE. Methods We conducted a retrospective chart review at Children’s Health Dallas (CHD), a tertiary pediatric hospital affiliated with the University of Texas Southwestern Medical Center (UTSW), the region’s largest pediatric academic center and home to the only comprehensive EoE program in North Texas. The study period spanned from January 1, 2013, to December 31, 2023. The Institutional Review Board (IRB) at UTSW approved the study as exempt, and institutional approval was obtained from CHD. The IRB or the study site did not require informed consent. Eligible patients were aged ≤ 18 years who had undergone airway flexible bronchoscopy with BAL and esophagogastroduodenoscopy (EGD) in the same encounter. The EoE group consisted of patients with biopsy-confirmed EoE based on esophageal histology (>15 eosinophils/high power) in the absence of other causes of eosinophilia. The control group included patients during the same period with a diagnosis of bronchopulmonary dysplasia (BPD), airway disorders, cystic fibrosis (CF), or primary ciliary dyskinesia (PCD), who underwent airway flexible bronchoscopy with BAL but did not have a diagnosis of EoE. Exclusion criteria included patients with known causes of BAL eosinophilia, such as eosinophilic pneumonia, parasitic infections, immunodeficiency states such as HIV infection, and drug reaction with eosinophilia and systemic syndrome (DRESS) [6,7]. Records were reviewed to collect the following information: demographic data (age, sex, race, ethnicity, and insurance coverage), clinical respiratory symptoms, medical history, and clinical data, including chest radiographs (CXR) or chest computed tomography (CT) if these had been completed within 30 days before the BAL. Flexible bronchoscopy, direct laryngobronchoscopy (DLB), EGD, nasopharyngeal laryngoscopy (NPL) findings, microbiology, and pathology results of biopsies and BAL cell counts were also captured. Additional clinical data included a complete blood count (CBC) and cell count differential, fractional exhaled nitric oxide (FeNO) levels and environmental allergen sensitization results obtained via skin prick testing or serum-specific Immunoglobulin E (IgE)measurement. Use of inhaled or systemic corticosteroids within 10 days of bronchoscopy, acid suppressants, and dupilumab use were also included in the analysis. Statistical analysis was performed using both Python and R. Demographic data for both the study and control groups were analyzed using Wilcoxon, Chi-Square, and Fisher’s exact tests. The study and control groups were compared using a logistic regression model, and the odds ratio was calculated to determine the odds of BAL eosinophilia in our study group compared to the control group. The primary outcome was BAL eosinophilia, defined as greater than 1% of the total cell count. Potential factors that may affect the outcome variable were identified. These included asthma, allergic rhinitis, eczema, and infections. Univariate and multivariate analyses were performed for these variables in both groups to analyze any confounding factors. Statistical significance was determined at an alpha level of 0.05. Results A total of 132 patients were reviewed, and 103 (45 with EoE and 58 controls) were analyzed. Twenty-nine charts were excluded due to missing data, including BAL cell count. The control group consisted of patients with BPD and airway anomalies (41%), cystic fibrosis (40%), and primary ciliary dyskinesia (19%). Demographics are shown in Table 1 . In the study group, 73% of the patients were male, whereas in the control group, 45% were male ( P = .004). The racial and ethnic composition of patients with and without EoE was similar. There was also no difference in primary insurance coverage. However, children with EoE were younger at the time of BAL (5 vs. 8 years, P = .003). Pulmonary symptomatology and medical diagnoses are shown in Table 2 . The most common respiratory symptoms and diagnoses were similar between groups. These included, in order of decreasing frequency, chronic cough, chronic rhinitis, and asthma. Gastrointestinal (GI) reflux symptoms were the most common non-respiratory symptoms for both the study and control groups, at 84% and 64%, respectively. Patients in the EoE group were more likely than controls to have associated asthma ( P = .011), allergic rhinitis ( P = .001), eczema ( P = 1 x 10 -5 ), GER ( P = .019), and food allergy ( P = 1 x 10 -5 ). In the study population, 36% of patients were found to have BAL eosinophilia, compared to 10% of patients in the control group (OR: 3.60, P = .002) ( Figure 1 ). Patients in the study group had an increased odds ratio (OR:4.99) of presenting with BAL eosinophilia compared to the control group ( P =.02). The odds of BAL eosinophilia in the three subgroups of control patients were lower compared to the study group. In patients with BPD and airway disorders and those with Cystic fibrosis, the decreased odds of BAL eosinophilia were statistically significant when compared to the study group. P values were .013 and .028, respectively, whereas in patients with PCD, it was not, P = .56. To determine whether the presence of BAL eosinophilia could be affected or associated with other BAL findings, the remainder of the differential cell count, lipid-laden macrophages (LLM), and bacterial, fungal, and viral studies were analyzed. None of these were statistically significant between the study and the control groups ( Table 3 ). Univariate ( Table 4) and multivariate analyses were conducted in the study group to establish the relationship between different atopic states and infectious organisms with BAL eosinophilia. Atopic conditions—including asthma, allergic rhinitis, and eczema, and infections—were associated with increased odds of BAL eosinophilia but neither was statistically significant: asthma (OR 1.45, 95% CI: 0.75–2.80, P =.26), allergic rhinitis (OR 2.50, 95% CI: 0.90–6.90, P =.08), eczema (OR 1.45, 95% CI: 0.65–3.25, P =.35), and infections (OR 1.45, 95% CI: 0.70–3.00, P =.32). All the patients with BAL eosinophilia were on inhaled steroids, but none received oral steroids prior to the procedure. One patient in each of the study and control groups was on asthma biologics (Dupilumab) prior to the procedure and did not show BAL eosinophilia. While other factors, such as imaging findings, FeNO, allergy testing, CBC eosinophils, and DLB procedural findings, were reviewed, these were not statistically analyzed due to the limited availability of data in our population. Discussion Although the gold standard for EoE diagnosis is esophageal biopsy, [1,3] a few small studies have analyzed BAL results in EoE. A study by Yawn, R.J. et al. found that the BAL neutrophil percentage and lipid-laden alveolar macrophage index (LLMI) are unreliable predictors of EoE in children [8]. Another study involving children with severe, uncontrolled asthma (SUA) and refractory asthma found a significant relationship between airway and esophageal eosinophils, focusing on eosinophils in endobronchial and esophageal biopsies [9]. Thus, a better understanding of the relationship between pulmonary symptoms and BAL findings in patients with EoE may lead to increased recognition, earlier diagnosis, and a decrease in complications. Our study demonstrates that pediatric patients with EoE have a higher prevalence of BAL eosinophilia than patients with chronic pulmonary conditions like cystic fibrosis, BPD, and airway anomalies. Asthma has been demonstrated to have BAL eosinophilia, which was identified in 36% of our patients with EoE, which is 3.6 times higher than that observed in the control group. To our knowledge, this is the first study to find this association in a pediatric population undergoing simultaneous bronchoscopy and endoscopy. Univariate and multivariate analyses in our study demonstrated that in our group of patients with EoE, atopic conditions, including asthma, were associated with an increased risk of BAL eosinophilia, but none were statistically significant. Our findings indicate that, within the appropriate clinical context, eosinophilic esophagitis should remain a diagnostic consideration, including among patients with concomitant asthma. Several notable demographic differences were observed between the study groups. EoE patients were younger and more likely to be male. The latter is consistent with the known epidemiologic evidence of male predominance in EoE [10]. In addition to BPD and airway disorders, the control group comprises patients with CF and PCD. BAL is frequently performed in these populations for surveillance cultures when there are concerns about disease exacerbation and/or progression. Lung function, as measured by spirometry, is one of the objective data used to determine disease exacerbation and progression [11,12]. Given developmental limitations, these tests cannot be performed reliably until approximately 5 years of age. This barrier could explain the older age observed in the control group. Bronchoscopy with BAL is typically offered to patients with underlying respiratory concerns. The control group consisted of children with conditions such as BPD, airway disorders, CF, and PCD—diseases that frequently prompt BAL for surveillance or diagnostic purposes. These entities are not known to be associated with BAL eosinophilia. Interestingly, when analyzed by subgroup, the prevalence of BAL eosinophilia was 4% in patients with BPD/airway disease, 9% in those with CF, and 18% in those with PCD. All control subgroups had lower odds of BAL eosinophilia than the EoE group. However, the difference was not statistically significant for the PCD subgroup, possibly due to its smaller sample size. These findings suggest that BAL eosinophilia in the setting of respiratory symptoms may warrant consideration of EoE, particularly when other common causes are excluded. Consistent with other studies [6], there was no statistically significant difference in the number of BAL neutrophils or LLM in the study versus the control groups. The study findings also align with the broader immunologic understanding of EoE as a T2 immune-mediated disorder. Previous studies have demonstrated a close association between EoE and atopic diseases such as asthma, eczema, and allergic rhinitis, as well as an association between BAL eosinophilia and other atopic diseases [13]. Our study confirmed this association with all atopic diseases, including asthma, allergic rhinitis, eczema, and food allergy, which had a statistically significantly higher prevalence in the EoE group than in the control group. However, BAL eosinophilia in our study group was not affected by the presence of these other atopic diseases. This finding suggests that EoE may independently contribute to lower airway eosinophilic inflammation, regardless of overlapping allergic disease. An alternative explanation is that the younger age of the patients in the EoE cohort may have influenced these findings. As these patients age, some may later receive a diagnosis of asthma as they develop characteristic clinical features and are able to perform reliable spirometry. Future studies should examine whether BAL eosinophilia could serve as a predictive biomarker for identifying patients with EoE who are at risk of developing eosinophilic asthma over time. Expectedly, in our study, patients with EoE had a higher prevalence of GI symptoms than those in the control group. There is limited data on the extra-gastrointestinal symptoms of patients with EoE. Consistent with previous data [14,15], our study demonstrated that patients with EoE have a significant prevalence of respiratory symptoms. Additionally, we showed that cough was as prevalent in the EoE population as GI symptoms of reflux. As previously suggested, EoE should be considered among the differential diagnoses in patients with chronic cough [4]. The most common respiratory and non-respiratory manifestations were the same in both the study group and the control group, suggesting that clinical symptoms alone may be insufficient to differentiate EoE from other pulmonary diagnoses. The differential considerations in pediatric patients with BAL eosinophilia include asthma, allergic bronchopulmonary aspergillosis, parasitic infections, allergic angiitis and granulomatosis, and idiopathic hyper-eosinophilic syndrome [6]. Our findings suggest that the presence of BAL eosinophilia should prompt consideration for EoE in the appropriate clinical scenario. If our data can be replicated in larger studies, it would suggest adding EoE as part of the differential considerations of airway eosinophilia. Study limitations reflect those associated with being conducted at a single center, limiting generalizability to different patient demographics. Also, the retrospective nature of EMR investigations limits the ability to establish cause-and-effect relationships. One of the issues associated with the retrospective nature of this study was the inability to collect clinical data from laboratories, imaging, and procedures that were missing. Another limitation is the nature of the control, which does not comprise healthy individuals or a single diagnosis, given that there is minimal to no data on bronchoscopy with BAL in healthy patients and limited data in single disease entities. To our knowledge, this is the first pediatric study to demonstrate a strong association between EoE and BAL eosinophilia. These findings underscore the importance of considering EoE in children with unexplained BAL eosinophilia or persistent respiratory symptoms. Future prospective multicenter studies are needed to validate these results and clarify the role of BAL in the diagnostic evaluation of eosinophilic esophagitis. Conflict of Interest: None of the authors has a conflict of interest to disclose. Funding statement Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award Number UL1 TR003163. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH (National Institutes of Health). Tables and Figures Table 1. Patient demographics of both the patients in the study group (EoE) and the control group. A P value of ≤ 0.05 marked with an asterisk (*) was considered significant. Age at BAL, median (IQR) 5 8 .003* Sex, no. (%) Male 33 (73) 26 (45) .004* Female 12 (27) 32 (55) Race, no. (%) White 31 (69) 35 (60) .70 Black 11 (24) 18 (31) Other 3 (7) 5 (9) Ethnicity, no. (%) Non-Hispanic 39 (87) 44 (76) .20 Hispanic 6 (13) 14 (24) Insurance, no. (%) Government 27 (60) 34 (59) .50 Private 18 (40) 24 (41) BAL, bronchoalveolar lavage Table 2. Symptomatology, medical diagnoses, and medications between the study (EoE) and control groups at the time of EGD and BAL. P values ≤ 0.05 are statistically significant and represented with an asterisk (*) Chronic Cough 38 (84) 42 (72) .145 Recurrent Croup 6 (13) 5 (9) .442 Stridor 8 (18) 4 (7) .088 DIAGNOSES, no (%) Allergic Rhinitis 33 (73) 24 (41) .001 * Eczema 25 (55) 8 (14) 1 x 10 -5* Asthma 25 (55) 14 (24) 0.011 * Food allergy 20 (44) 4 (7) 1 x 10 -5* MEDICATIONS, no. (%) ICS Use 41 (91) 43 (74) .154 Steroid Use 3 (67) 3 (52) .748 Chronic Acid Suppression 38 (84) 31 (53) .002 * Dupixent 1 (2) 1 (2) .856 GI, gastrointestinal; ICS, inhaled corticosteroids Table 3. Logistic Regression Model comparing BAL eosinophilia in control vs EoE group. P values ≤ .05 are statistically significant and represented with an asterisk (*). EoE 4.99 (1.90-14.89) .002* BPD/Aerodigestive 0.07 (0.00-0.39) .01* Cystic Fibrosis 0.17 (0.03-0.69) .03* PCD 0.65 (0.13-2.56) .56 Table 4. Univariate analysis of atopic conditions and BAL eosinophilia in patients with EoE. Asthma 1.46 (0.44-5.06) 0.54 Allergic Rhinitis 2.50 (0.62-12.82) 0.22 Eczema 1.46 (0.44-5.06) 0.54 BAL Infection 1.45 (0.45-4.69) 0.53 Figure 1. Proportion of BAL Eosinophilia in EoE vs. Control Groups. P values ≤ 0.05 are statistically significant and represented with an asterisk (*). References 1. Lucendo, A.J., et al., Guidelines on eosinophilic esophagitis: evidence‐based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterology Journal, 2017. 5 (3): p. 335-358. 2. Roh, J.H., E. Ryoo, and H. Tchah, Clinical Manifestations of Eosinophilic Esophagitis in Children and Adolescents: A Single-Center, Matched Case-Control Study. Pediatric Gastroenterology, Hepatology & Nutrition, 2020. 23 (4): p. 319. 3. Papadopoulou, A., et al., Joint ESPGHAN/NASPGHAN Guidelines on Childhood Eosinophilic Gastrointestinal Disorders Beyond Eosinophilic Esophagitis. Journal of Pediatric Gastroenterology and Nutrition, 2024. 78 (1): p. 122-152. 4. Fracchia, M.S., et al., The diagnostic role of triple endoscopy in pediatric patients with chronic cough. International Journal of Pediatric Otorhinolaryngology, 2019. 116 : p. 58-61. 5. Hill, C.A., et al., Prevalence of eosinophilic esophagitis in children with refractory aerodigestive symptoms. JAMA Otolaryngol Head Neck Surg, 2013. 139 (9): p. 903-6. 6. Ribeiro, J.D. and G.B. Fischer, Eosinophilic lung diseases. Paediatric Respiratory Reviews, 2002. 3 (4): p. 278-284. 7. De Giacomi, F., et al., Acute Eosinophilic Pneumonia. Causes, Diagnosis, and Management. Am J Respir Crit Care Med, 2018. 197 (6): p. 728-736. 8. Yawn, R.J., et al., The utility of bronchoalveolar lavage findings in the diagnosis of eosinophilic esophagitis in children. International Journal of Pediatric Otorhinolaryngology, 2015. 79 (11): p. 1834-1837. 9. Erkman, J., et al., Airway and esophageal eosinophils in children with severe uncontrolled asthma. Pediatric Pulmonology, 2018. 53 (12): p. 1598-1603. 10. Sperry, S.L., et al., Influence of Race and Gender on the Presentation of Eosinophilic Esophagitis. American Journal of Gastroenterology, 2012. 107 (2): p. 215-221. 11. Walicka-Serzysko, K., et al., Pulmonary Function Tests in the Evaluation of Early Lung Disease in Cystic Fibrosis. Journal of Clinical Medicine, 2023. 12 (14): p. 4735. 12. Ferraro, V.A., et al., Lung Function in Children with Primary Ciliary Dyskinesia. Children, 2023. 10 (2): p. 290. 13. Capucilli, P. and D.A. Hill, Allergic Comorbidity in Eosinophilic Esophagitis: Mechanistic Relevance and Clinical Implications. Clin Rev Allergy Immunol, 2019. 57 (1): p. 111-127. 14. Rubinstein, E. and R.L. Rosen, Respiratory symptoms associated with eosinophilic esophagitis. Pediatric Pulmonology, 2018. 53 (11): p. 1587-1591. 15. Hirsch, S., Cohen, A., Rahbar, R., Rubinstein, E., & Rosen, R. (2023). Characterization of Eosinophilic Esophagitis in Infants and Toddlers. Journal of Pediatric Gastroenterology and Nutrition , 77 (1), 86–92 Information & Authors Information Version history V1 Version 1 18 September 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords eosinophils esophagitis pediatrics Authors Affiliations Yadira M. Rivera Sánchez 0000-0003-0625-4741 [email protected] The University of Texas Southwestern Medical Center View all articles by this author Yutika Mandal VCU Health System View all articles by this author Princy Ghera The University of Texas Southwestern Medical Center View all articles by this author Stephen Chorney 0000-0003-1419-6019 The University of Texas Southwestern Medical Center View all articles by this author Akaash Goyal The University of Texas Southwestern Medical Center View all articles by this author John Bird 0000-0003-3772-6078 The University of Texas Southwestern Medical Center View all articles by this author Christopher Parrish no affiliation View all articles by this author Michael Dang The University of Texas Southwestern Medical Center View all articles by this author Metrics & Citations Metrics Article Usage 218 views 178 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Yadira M. Rivera Sánchez, Yutika Mandal, Princy Ghera, et al. Manuscript Title: Bronchoalveolar lavage eosinophilia and pulmonary symptoms in pediatric eosinophilic esophagitis. Author Information. Authorea . 18 September 2025. DOI: https://doi.org/10.22541/au.175821353.34231012/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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