eosinophilic esophagitis ( eoe ) is a commonly recognized pediatric condition that has emerged as a disorder increasingly affecting adults . although eoe has been documented in all ages , races and genders , the typical eoe patient is an adult male with prior history of atopy . eoe is characterized by chronic , immune / antigen - mediated esophageal dysfunction with eosinophil - predominant inflammation . incidence rates of eoe have increased over the past decade beyond what would be expected by increased recognition alone [ 1 , 2 ] . food impaction , chest pain , upper abdominal pain , symptoms of gastroesophageal reflux disease ( gerd ) and globus have also been reported in some adults with eoe [ 5 , 6 ] . new consensus recommendations released in 2011 established a minimum peak value of 15 eosinophils / hpf as a requirement for a diagnosis of eoe with few exceptions . additionally , due to an increasing prevalence of proton pump inhibitor - responsive esophageal eosinophilia , therapeutic trials of proton pump inhibitor or ph monitoring were recommended to aid in distinguishing eoe from gerd . studies have demonstrated both clinical and histologic response to ( 1 ) strict elemental diet , ( 2 ) diet restriction based on allergy testing , and ( 3 ) diet restriction based on eliminating the more common food allergens . corticosteroids have also been proven to be effective in treating eoe , however clinical and histologic features are known to return with discontinuation of therapy . here we report the case of a 24-year - old female who was diagnosed with eoe with an atypical presentation . a 24-year - old woman was referred to our care in march 2011 with a 3-year history of persistent hiccups and mild , intermittent dyspepsia . her symptoms began with episodic mild chest discomfort lasting one minute followed by bouts of hiccups . over time , the hiccups progressed to up to 10 episodes per day . she had no prior medical history other than one admission for renal calculi , and her only prescription was birth control pills . she had no history of allergy and no known family history of illness as she was adopted . six months before our evaluation she was treated empirically with ranitidine with no relief of her symptoms . she underwent esophagogastroduodenoscopy ( egd ) , which demonstrated trachealization of the esophagus , and biopsies from the distal esophagus showed significant eosinophilic infiltration . she was subsequently placed on a 6-week course of high - dose omeprazole ( 40 mg twice daily ) , with minimal relief of her symptoms . a follow - up egd showed persistent trachealization and esophageal eosinophilia ( peak eosinophil count of 23/hpf ) consistent with a diagnosis of eoe ( fig . her symptoms improved substantially within 1 week , with hiccups occurring fewer than 2 times per week . a repeat egd while on treatment demonstrated resolution of trachealization , and biopsies showed histologic remission of eoe ( peak eosinophil count of 5/hpf ) . fluticasone was subsequently discontinued , but the patient developed recurrent hiccups within a few days . they are an involuntary spasmodic contraction of the diaphragm and intercostal muscles , resulting in sudden inspiration and closure of the glottis . multiple causes of hiccups have been described , including gastric or esophageal distention due to overeating or carbonated beverages , phrenic nerve irritation , central nervous system disorders , metabolic , postoperative and psychogenic disorders , medication side effects and reflux esophagitis . the pathogenesis is unclear , but one proposed mechanism suggests that esophageal receptors send impulses via the vagal nerve to respiratory motor neurons , resulting in hiccups . eoe is a chronic , immune / antigen - mediated esophageal disease characterized histologically by eosinophil - predominant inflammation and clinically by symptoms related to esophageal dysfunction . due to overlapping clinical features , the diagnosis of eoe requires distinction from gerd with a trial of a proton pump inhibitor or with ph monitoring . esophageal eosinophilia led to the initial suspicion of gerd and the initiation of acid - modifying therapy . our patient achieved minimal relief with an h2 blocker or proton pump inhibitor , suggesting that hiccups were unlikely related solely to gerd . by contrast , the patient 's clinical , endoscopic and histologic response to topical steroid therapy supports an association between hiccups and eoe and suggests that eoe be considered in the differential diagnosis of patients with refractory hiccups . the international gastrointestinal eosinophil researchers ( tigers ) concept award ( support to p.a.b . and j.l . ) .