Allergy Grand Rounds

Michael Goldman, M.D.

Johns Hopkins Asthma & Allergy Center
April 2, 2004
 Chief Complaint

This is a 37 y.o. WM who presents with

dysphagia of solid foods for three years
 HPI
Complains of difficulty swallowing solid foods.
Steak, chicken, pork, and bread get stuck in the
base of throat  emesis, with relief of
obstruction
No pain on swallowing, no heartburn, no wt. loss
No difficulty swallowing liquids
Only slight improvement with Nexium. Stopped
due to nausea.
Referred to GI
 Work up
 Normal Exam
 Barium swallow: narrowing of distal esophagus.
 Differential diagnosis:
 Peptic stricture (from reflux esophagitis), but no history of
reflux
 Motility disorder (eg achalasia, esophageal spasm) but no
mention of abnormal motility or dilated esophagus on
barium swallow
 Hypertensive lower esophageal sphincter
 Schatzki ring (Lower esophageal mucosal ring)
Achalasia
Schatzki Ring
 Work up
 Endoscopy:
 “Ringed” esophagus
 Several “polypoid/nodular” areas, biopsied

 Narrowing of the distal esophagus

 Not consistent with Schatzki ring
 Stricture dilated
Ringed Esophagus
Esophageal nodules
Whitish exudates
Esophageal Stricture with Food
Impaction
 Biopsy Results
 Esophagus:
 Moderate chronic inflammation
 Focally parakeratotic (excessive keratin) papillary
tissue with increased areas of eosinophils in
subepithelium
 Read as compatible with squamous papilloma with
eosinophilia described in reflux esophagitis.
 No dysplasia
Eosinophilic Esophagitis

Referred for allergy evaluation

 Allergy Consultation
 Dysphagia of solids persists, but no further
vomiting episodes since esophageal dilitation.
 No history of food allergy, but on careful
questioning reports slight itchy throat to
peanuts, eggs, possibly nuts.
 Beer causes facial flushing and mild throat
constriction. No reactions to other forms of
alcohol.
 Medical/Social History
 Allergic rhinitis as a child, treated with
immunotherapy. Mild symptoms presently
except around pets.
 Mild asthma around pets and with exercise in
cold air. Uses albuterol prn. No steroids or ER
visits since childhood.
 Otherwise healthy: no cardiac disease, rashes,
arthritis, fevers, chills, diarrhea, travel
 No pets, non smoker, no ETOH abuse.
 Physical Exam
 Normal
 No edema of nasal mucosa
 Clear lungs

 Cardiac without murmurs

 Normal abdominal exam

 Diagnostic testing performed

 What would you test for?
 Skin Testing-scratch
Food Wheal/flare Food Wheal/flare

Egg 10/45 Malt 5/12

Peanut 7/20 Wheat 3/5
Fish Mix 6/30 Beef 0
Hazelnut 10/30 Chicken 0
Almond 4/8 Milk 0
Other nuts 0 Soy 0
Pork 4/12 Shellfish mix 0
Lamb 5/15
 Now What?
 More skin testing?
 Confirm with RAST?
 Food patch testing?
 Other blood tests?
 Food avoidance?
 Epipen?
 Medicines?
 My recommendations
 Food avoidance for 1 month: all positive skin
tests except wheat (borderline)
 Egg, peanut, beer (malt), hazelnut, almond, pork,
lamb.
 Confirm positive tests with cap-Rast.
 Check CBC, eosinophil count, total IgE
 No meds prescribed
 Blood results
Food kU/L Food kU/L
Egg 4.88 Malt 3.32
Peanut 2.56 Wheat 12.3
Fish (cod, <0.35
tuna,salmon)
Hazelnut 3.32 Total IgE 627(0-114)
Almond 3.37 Serum Eos 871 (15-500)
Pork 4.57 WBC 6.7K,13%eos
Lamb 3.43
 Follow Up
 Improved but not resolved
 Still with some dysphagia but no choking or
vomiting (since dilitation)
 Avoiding egg, pork, lamb, fish, malt, peanuts,
and nuts
 Skin tests to individual fish all + except tuna
 Skin tests to inhalants +cat, dog, DM, trees,
grass.
 No seasonal worsening of dysphagia
 Now What?
 Recommended wheat avoidance for 2 weeks,
symptoms partially improved
 Pt not interested in neocate trial
 To start Flovent 220 2 p bid, without spacer,
swallowed.
 GI follow up in 2 months.
 Adult Eosinophilic Esophagitis
 Typically seen in young adults (mean age 34)
 Dysphagia with bolus impaction is most
common symptom
 Esophageal strictures common (unlike kids)
 Esophageal biopsy necessary for diagnosis
 Exclude secondary causes: HES, parasitic
disease, connective tissue dz (scleroderma), drug
reaction
 Adult Eosinophilic Esophagitis
 Mean duration to diagnosis 4 years
 Male : Female = 3 : 1
 50 – 75% atopic
 Food sensitization common, but not well
studied
 Pediatric Eosinophilic Esophagitis
 Reflux symptoms most common presentation
 Vomiting
 Regurgitation

 Abdominal pain

 Dysphagia

 Food refusal/poor wt. gain

 Unresponsive to PPIs for GERD

 Strictures less common
 Pediatric Eosinophilic Esophagitis
 Endoscopy and biopsy needed for diagnosis
 Food sensitization very common
 60-75% skin test positive (egg, milk most common)
 80% in one study positive patch test to foods (wheat
most common)1

1Spergel, JACI 2002, 109:363-368

 Treatment
 Food avoidance
 Effective in children
 Elemental formula reduced eosinophils and symptoms1
 8/10 resolution, other 2 improved
 Food avoidance based on all positive skin test and food
patch test:2
 resolved symptoms in 18/24 kids w/ EE and improved
symptoms other 6. Milk, egg most common, but many others
implicated. Average of 3.6+/-2.1 foods
 Mean esophageal eosinophils decreased 55.8/hpf8.4/hpf
 No studies in adults

1Kelly,
Gastroenterology, 1995, 1503-1512
2Spergel, JACI 2002, 109:363-368
 Treatment
 Oral corticosteroids
 Effective but side effects
 Topical Steroids (swallowed “inhaled” steroids)
 Swallow FP 220 2pbid
 Improvement in both adults and children

 Esophageal candidiasis (2/13 kids)1

1Teitlebaum, Gastroenterology 2002;122:1216

 Treatment
 Esophageal dilitation
 Relieves obstruction, dysphagia often persists
 PPIs for EE generally ineffective
 EE vs. GERD
Characteristic EE GERD
Atopy High Nml
Food sensitization High Nml
Histology >24 eos/hpf 0-7 eos/hpf
Peripheral eosinophilia ~50% rare
Esophageal pH Normal Abnormal
PPI Usually not Helpful
helpful
Steroids Helpful Not helpful
Food allergen elimination Sometimes Not helpful
helpful