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 w

dysphagia of solid foods for three y

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/flar
e

Food

Wheal/flar
e

Egg
Peanut
Fish Mix
Hazelnut
Almond
Other nuts
Pork

10/45
7/20
6/30
10/30
4/8
0
4/12

Malt
Wheat
Beef
Chicken
Milk
Soy
Shellfish
mix

5/12
3/5
0
0
0
0
0

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
Egg
Peanut
Fish (cod,
tuna,salm
on)
Hazelnut

kU/L
4.88
2.56
<0.35

Food
Malt
Wheat

kU/L
3.32
12.3

3.32

Almond

3.37

Pork

4.57

Total IgE 627(0114)

Serum
871 (15Eos
500)
WBC
6.7K,13%

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

Spergel, JACI 2002, 109:363-368

Treatment

Food avoidance

Effective in children

Elemental formula reduced eosinophils and

symptoms1

Food avoidance based on all positive skin test

and food patch test:2

8/10 resolution, other 2 improved

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/hpf8.4/hpf

No studies in adults

Kelly, Gastroenterology, 1995, 1503-1512

2
Spergel, JACI 2002,
1

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

Teitlebaum, Gastroenterology 2002;122:1216

Treatment

Esophageal dilitation

Relieves obstruction, dysphagia often

persists

PPIs for EE generally ineffective

EE vs. GERD
Characteristic
Atopy
Food sensitization
Histology
Peripheral
eosinophilia
Esophageal pH
PPI
Steroids

EE
High
High
>24
eos/hpf
~50%

GERD
Nml
Nml
0-7
eos/hpf
rare

Normal
Usually not
helpful
Helpful

Abnormal
Helpful
Not