Eosinophil Esophagitis

Patients who have outgrown their food allergies can develop eosinophilic esophagitis as a reaction to the same foods, a new study shows.

“Two to 4 years later, they come back with a different allergy,” said Jonathan Spergel, MD, chief of the allergy section of The Children’s Hospital of Philadelphia in Pennsylvania. “Initially, they are getting anaphylactic shock to this food. Now they are getting a swollen esophagus.”

Dr. Spergel presented the study results at the American Academy of Allergy, Asthma & Immunology 2014.

According to the AAAAI, EE is only recently recognized as a chronic, often painful, allergy/immune condition that involves swelling and inflammation of the esophagus. Eosinophilic esophagitis is characterized by the presence of a large number of white blood cells, called eosinophils, in the tissue of the esophagus, which causes inflammation or swelling. Infants and toddlers with the ailment may refuse food and, thus, grow improperly. School-aged children may complain of abdominal pain, difficulty swallowing, or nausea and vomiting. Teenagers and adults most often note difficulty swallowing. Swelling of the esophagus can progress to the point where food gets stuck, becoming a medical emergency.
Recent research has suggested that the mechanism of disease of eosinophilic esophagitis is independent of immunoglobulin E, a key mediator of typical food allergies.

To measure the frequency of food allergy in patients with eosinophilic esophagitis, Dr. Spergel and his team studied 1025 children treated for the condition.

Just because you now tolerate a food doesn’t mean you’re absolutely clear.
A specific food was identified as the culprit in 425 of those children. A food was considered to cause eosinophilic esophagitis if removing it from the diet stopped symptoms or if reintroducing it into the diet caused symptoms to reoccur.

For these 425 children, the most common triggers were milk, egg, wheat, and soy.

A total of 17 patients developed an eosinophilic esophagitis reaction to a food after they outgrew an allergy to that same food. Milk, egg, wheat, and soy were still the most common esophagitis triggers in this subgroup, and 94% of the patients had atopic disease.

The investigators noted that 2 children had normal biopsies of the esophagus when they had a food allergy. After they outgrew that food allergy, they developed an esophagitis reaction to the same food when that food was reintroduced into their diet.

This study focused on patients who naturally outgrew their food allergies, but about 10% to 15% of patients who undergo oral immunotherapy for their food allergies also develop esophagitis, noted Wesley Burks, MD, physician in chief at North Carolina Children’s Hospital in Chapel Hill.

Clinicians should be aware of the symptoms of eosinophilic esophagitis in patients with a history of food allergies, said Dr. Spergel. “When patients outgrow milk or peanut allergies, you need to worry if they come back 2 or 6 months later with abdominal pains and flu-like symptoms. You need to go back and look at whether the food they couldn’t eat a few years ago is causing these new symptoms.”

“I think Dr. Spergel has a very good point that just because you now tolerate a food doesn’t mean you’re absolutely clear,” said Hugh Sampson, MD, professor of pediatrics, allergy, and immunology at the Mount Sinai Hospital in New York City.

Dr. Sampson speculated that patients with typical food allergies might start out susceptible to esophagitis, but be unaware of the condition because they are avoiding the food.

Patients who outgrow their allergies to foods then develop esophagitis in reaction to these foods must once again avoid them, said Dr. Spergel.

The most common treatments for the condition are to swallow small doses of corticosteroids or to inhale corticosteroid asthma medications, he noted.

Dr. Spergel reported financial relationships with Dannone, DBV Technologies, and MEI Pharma. Dr. Burks has disclosed no relevant financial relationships. Dr. Sampson reports relationships with Dannone, ThermoFisher Scientific, Allertein Therapeutics, Regeneron, Novartis, and UpToDate, among others.

American Academy of Allergy, Asthma & Immunology (AAAAI) 2014: Abstract 990. Presented March 2, 2014.