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Background: Equine grass sickness (EGS) has been reported in several European and extra-European countries. Despite this, no scientific paper about clinical cases of EGS in Italy has been published. EGS is a disease affecting almost exclusively horses kept on pasture, characterized by clinical signs related to lesions in autonomic nervous system (ANS), particularly in the enteric nervous system (ENS). According to clinical presentation, acute, subacute and chornic syndromes can be observed, with various sympthoms including dullness, anorexia, dysphagia, drooling of saliva, tachycardia, ptosis, patchy sweating and muscle fasciculations. In horses affected by acute forms, mild to moderate abdominal pain and large volumes of nasogastric reflux can be observed. The etiology is still speculative and many hypothesis have been proposed to explain the pathogenesis. Case presentation: The present study describes four cases of EGS (one subacute and three chronic forms) occurred in Central Italy during early spring. In all the cases included in the study, the prognosis was poor and the horses were euthanized. The diagnosis was confirmed by histological examination of ANS or ENS. In two cases, in vivo diagnosis was obtained by histological examination of enteric bioptic samples collected during laparoscopy. Conclusions: EGS in Italy could be underdiagnosed and incidence understimated. Greater awareness should be applied in Italy for the inclusion of EGS in differential diagnosis for horses presenting clinical signs of abdominal pain associated or not with gastric reflux and muscular fasciculation. All the cases in this study concerned horses kept in the same pasture, confirming a possible premise-linked and management-linked factors on the ethiopathogenesis of EGS. The age of horses ranged from 2 to 6 years, that is consistent with the risk factor age for EGS (from 2 to 7 years of age). Previous suspected EGS diagnosis in the same livestock and recent cool dry weather were considered additional potential risk factors. [ABSTRACT FROM AUTHOR]