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Platts-Mills TAE, Commins SP. Emerging antigens involved in allergic responses. Curr Opin Immunol 2013; 25:769-74. [PMID: 24095162 DOI: 10.1016/j.coi.2013.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 09/04/2013] [Accepted: 09/06/2013] [Indexed: 10/26/2022]
Abstract
New allergic diseases can 'emerge' because of exposure to a novel antigen, because the immune responsiveness of the subject changes, or because of a change in the behavior of the population. Novel antigens have entered the environment as new pests in the home (e.g., Asian lady beetle or stink bugs), in the diet (e.g., prebiotics or wheat isolates), or because of the spread of a biting arthropod (e.g., ticks). Over the last few years, a significant new disease has been identified, which has changed the paradigm for food allergy. Bites of the tick, Amblyomma americanum, are capable of inducing IgE antibodies to galactose-alpha-1,3-galactose, which is associated with two novel forms of anaphylaxis. In a large area of the southeastern United States, the disease of delayed anaphylaxis to mammalian meat is now common. This disease challenges many previous rules about food allergy and provides a striking model of an emerging allergic disease.
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Affiliation(s)
- Thomas A E Platts-Mills
- Department of Medicine, Division of Allergy and Immunology, University of Virginia Health System, Charlottesville, VA, USA.
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252
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Dhaliwal J, Tobias V, Sugo E, Varjavandi V, Lemberg D, Day A, Bohane T, Ledder O, Jiwane A, Adams S, Henry G, Dilley A, Shi E, Krishnan U. Eosinophilic esophagitis in children with esophageal atresia. Dis Esophagus 2013; 27:340-7. [PMID: 23947919 DOI: 10.1111/dote.12119] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) has only rarely been reported in esophageal atresia (EA) patients. A retrospective case analysis of all EA patients born at our center between January 1999 and April 2012 was performed. A total of 113 of patients were identified; 10 patients were excluded as a result of inadequate data. Eighteen patients (17%) were diagnosed with EoE. The average number of eosinophilis was 30/high-power field (HPF) (19/HPF-80/HPF). The median age for diagnosis of EoE was 1 year and 6 months (8 months-8 years and 7 months). Children with EoE had a significantly greater incidence of reflux symptoms, dysphagia, tracheomalacia, and 'hypoxic spells' (P < 0.05). EoE patients also underwent significantly more surgery including fundoplication and aortopexy when compared with those without EoE (P < 0.0001). Although the incidence of gastrostomy was greater in the EoE group (33% vs. 13%), this was not statistically significant. Half of the EoE patients had a coexisting atopic condition at time of diagnosis. The commonest condition was asthma 7/18 (38%) followed by specific food allergy 6/18 (33%). EoE was treated in 11 patients with either swallowed fluticasone or budesonide slurry. All improved clinically. Histologically, five had complete resolution and six had partial improvement. Six children with EoE were treated with acid suppression alone. All improved clinically, and 5/6 had subsequent histological resolution. One child who received acid suppression and an exclusion diet also improved. Seven patients (38%) had an esophageal stricture at time of EoE diagnosis. Five were dilated at time of the initial endoscopy, prior to the diagnosis of EoE being available. Two patients had resolution of their strictures on medical treatment of their EoE alone and did not require further dilatation. EoE was seen in 17% of children with EA in this study. EoE should be considered in EA patients with persistent symptoms on standard reflux treatment, increasing dysphagia, and recurrent strictures.
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Affiliation(s)
- J Dhaliwal
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
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Lucendo AJ, Arias Á, González-Cervera J, Mota-Huertas T, Yagüe-Compadre JL. Tolerance of a cow's milk-based hydrolyzed formula in patients with eosinophilic esophagitis triggered by milk. Allergy 2013; 68:1065-72. [PMID: 23906026 DOI: 10.1111/all.12200] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cow's milk protein, a major food trigger for EoE in both children and adults, should be continuously avoided once identified as such. This study evaluates tolerance of a cow's milk-based extensively hydrolyzed formula (eHF) with regard to disease remission maintenance in adult patients with milk-triggered EoE. METHODS Seventeen adult patients in whom cow's milk was consecutively demonstrated to trigger EoE after an empiric six-food elimination diet-based study protocol and who subsequently maintained disease remission were prospectively recruited. They were given 400 ml of a cow's milk-based eHF daily for 8 weeks. Intraepithelial peak eosinophil and blood eosinophil counts, esophageal-related symptoms, serum total and specific IgE to major milk proteins, and eosinophil cationic protein were monitored before and after eHF intake. RESULTS Thirteen male and four female patients aged 17-56 completed the study protocol. 15 patients (88.24%) achieved and maintained EoE remission, while an infiltration of ≥15 eosinophils/hpf reappeared in the remaining two patients. No differences in age, gender, symptoms, and endoscopic appearance at baseline conditions or personal/family allergic background were observed between those patients who tolerated the eHF and those who did not. Symptom scores did not significantly change after eHF intake and were significantly lower than those documented at baseline conditions or after cow's milk challenge. No differences were documented in blood eosinophil counts or serum markers after eHF intake. CONCLUSION Most adult patients with EoE triggered by cow's milk tolerate a cow's milk-based eHF, thus providing them with a safe, economical alternative to cow's milk.
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Affiliation(s)
- A. J. Lucendo
- Department of Gastroenterology; Hospital General de Tomelloso; Ciudad Real; Spain
| | - Á. Arias
- Research Support Unit; Complejo Hospitalario La Mancha Centro; Ciudad Real; Spain
| | | | - T. Mota-Huertas
- Department of Pathology; Complejo Hospitalario La Mancha Centro; Ciudad Real; Spain
| | - J. L. Yagüe-Compadre
- Department of Pathology; Complejo Hospitalario La Mancha Centro; Ciudad Real; Spain
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254
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Abstract
CME EDUCATIONAL OBJECTIVES 1. Determine the clinical presentation and diagnostic criteria for eosinophilic esophagitis in children. 2. Discuss the three major treatment strategies for eosinophilic esophagitis. 3. Provide key strategies for practical identification and management of eosinophilic esophagitis in children and adolescents. Eosinophilic esophagitis (EoE) is a recently discovered disease that affects patients worldwide. The conceptual definition of EoE is a chronic, immune/antigen-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. As a chronic, antigen-mediated disease causing eosinophilic inflammation in the esophagus, EoE symptoms are similar to gastroesophageal reflux disease (GERD) and it results in significant morbidity.
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Affiliation(s)
- Carla M Davis
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA.
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255
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Abstract
PURPOSE OF REVIEW With the increasing recognition of eosinophilic esophagitis (EoE) over the past two decades, pharmacologic and dietary therapies have emerged as primary management options. The effectiveness of the elimination dietary therapy supports the conceptual definition of EoE as an antigen/immune-mediated esophageal disease. This manuscript reviews the three types of dietary therapy: an elemental formula diet with complete elimination of table foods, an allergy testing-directed elimination diet and an empiric elimination diet based on common food allergens. RECENT FINDINGS Recent prospective studies have demonstrated symptomatic and histologic response to an elimination diet in adults with EoE that is comparable with response rates previously reported in children. Retrospective, comparative data in pediatric EoE have identified the elemental diet as offering the greatest likelihood of histologic disease remission compared with either allergy testing-directed or empiric elimination diets. The long-term goal of each dietary approach is the eventual identification of a single or limited number of trigger foods, thereby allowing a return to as regular a diet as possible. SUMMARY Studies continue to support dietary therapy as an important and effective therapy for EoE. Although topical steroids continue to be a mainstay of therapy, none are presently Food and Drug Administration-approved for EoE. In addition, many patients are reluctant to utilize pharmacologic therapy on a chronic basis. Further research is necessary to better understand and optimize the use of diet therapy for EoE.
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256
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Simon D, Straumann A, Dahinden C, Simon HU. Frequent sensitization to Candida albicans and profilins in adult eosinophilic esophagitis. Allergy 2013; 68:945-8. [PMID: 23735202 DOI: 10.1111/all.12157] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is often associated with atopic airway and skin diseases. More than 80% of EoE patients are sensitized to aero- and/or food allergens. Immunoglobulin (Ig)E-mediated immune responses to microbes have been reported to be deleterious in connection with atopic diseases. AIM The aim of this study was to obtain a comprehensive overview about the sensitization spectrum of adult EoE patients. METHODS IgE in sera of 35 patients with active EoE were analyzed for reactivity to Candida albicans, as well as to a panel of recombinant and purified natural allergen components, using a microarray. RESULTS IgE sensitization to Candida albicans was found in 43% of EoE patients. More than 80% of EoE patients were sensitized to aeroallergens and 22% to food-specific allergen components, whereas 69% of the patients exhibited specific IgE to cross-reactive allergens. Among the latter, profilins were identified as most frequent IgE cross-reactive allergen components. Interestingly, dysphagia, the main symptom of adult EoE patients following rice and/or bread ingestion, was associated with sensitization to cross-reactive allergens such as profilins, pathogenesis-related (PR) 10 and lipid transfer proteins (LTP). Intolerance toward meat rarely correlated with sensitization to animal food allergens. CONCLUSION Candida albicans and cross-reactive plant allergen components, in particular profilins, were identified as frequent sensitizers in adult EoE patients. Specific elimination therapies are suggested to reveal their actual roles in the pathogenesis of EoE.
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Affiliation(s)
- D. Simon
- Department of Dermatology; Inselspital; Bern University Hospital; Bern; Switzerland
| | - A. Straumann
- Department of Gastroenterology; Kantonsspital Olten; Bern; Switzerland
| | - C. Dahinden
- Institute of Immunology; Inselspital; Bern University Hospital; Bern; Switzerland
| | - H.-U. Simon
- Institute of Pharmacology; University of Bern; Bern; Switzerland
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The management of eosinophilic esophagitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:332-40; quiz 341-2. [PMID: 24565538 DOI: 10.1016/j.jaip.2013.05.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 05/20/2013] [Accepted: 05/22/2013] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) is a clinicopathologic, chronic esophageal inflammatory disease resistant to acid suppressive therapy and is associated with variable symptoms indicative of upper gastrointestinal dysfunction. Per current guidelines established by The International Group of Eosinophil Researchers (TIGERS), the diagnosis is made in symptomatic patients after a biopsy that confirms a peak eosinophil level of ≥15 eosinophils/high-powered field (HPF). The esophagus is distinguished by pronounced tissue eosinophilia in which dietary antigens are key inciting factors for disease pathogenesis; EoE being reversed by elimination of triggering food allergens suggests that the disease is mediated in part by allergic sensitization to foods. Moreover, experimental EoE in mice can be induced not only via food exposure but also via aeroallergen exposure. Consistent with an allergic etiology rather than an acid-induced esophagitis, swallowed glucocorticoids are effective for the treatment of EoE. Evaluation by an allergist is a recommended part of the diagnostic workup, especially for management of allergic comorbidities. Clinical practice for the evaluation of patients with EoE mainly relies on prick skin tests due to the ease and validation of these tests in the context of immediate hypersensitivity. However, both atopy patch testing and serum IgE testing have been used in EoE. Herein, we reviewed the basic clinical features of EoE with a focus on the approach to diagnosing causative food allergens and to dietary therapy.
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258
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Eosinophilic esophagitis: A practical primer for an atypical disease. JAAPA 2013; 26:54-7. [PMID: 23682457 DOI: 10.1097/01720610-201305000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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259
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Mane SK, Jordan PA, Bahna SL. Eosinophilic esophagitis to unsuspected rare food allergen. Ann Allergy Asthma Immunol 2013; 111:64-5. [PMID: 23806462 DOI: 10.1016/j.anai.2013.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 04/02/2013] [Accepted: 04/02/2013] [Indexed: 01/07/2023]
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260
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Spergel JM, Cianferoni A. Treatment of eosinophilic esophagitis. Expert Opin Orphan Drugs 2013. [DOI: 10.1517/21678707.2013.772494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Eigenmann PA, Atanaskovic-Markovic M, O'B Hourihane J, Lack G, Lau S, Matricardi PM, Muraro A, Namazova Baranova L, Nieto A, Papadopoulos NG, Réthy LA, Roberts G, Rudzeviciene O, Wahn U, Wickman M, Høst A. Testing children for allergies: why, how, who and when: an updated statement of the European Academy of Allergy and Clinical Immunology (EAACI) Section on Pediatrics and the EAACI-Clemens von Pirquet Foundation. Pediatr Allergy Immunol 2013; 24:195-209. [PMID: 23506293 DOI: 10.1111/pai.12066] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2013] [Indexed: 12/20/2022]
Abstract
Allergic diseases are common in childhood and can cause a significant morbidity and impaired quality-of-life of the children and their families. Adequate allergy testing is the prerequisite for optimal care, including allergen avoidance, pharmacotherapy and immunotherapy. Children with persisting or recurrent or severe symptoms suggestive for allergy should undergo an appropriate diagnostic work-up, irrespective of their age. Adequate allergy testing may also allow defining allergic trigger in common symptoms. We provide here evidence-based guidance on when and how to test for allergy in children based on common presenting symptoms suggestive of allergic diseases.
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Affiliation(s)
- P A Eigenmann
- Department of Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland.
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262
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Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated condition whereby infiltration of eosinophils into the esophageal mucosa leads to symptoms of esophageal dysfunction. EoE is encountered in a substantial proportion of patients undergoing diagnostic upper endoscopy. This review discusses the clinical, endoscopic, and histologic features of EoE and presents the most recent guidelines for its diagnosis. Selected diagnostic dilemmas are described, including distinguishing EoE from gastroesophageal reflux disease and addressing the newly recognized clinical entity of proton-pump inhibitor-responsive esophageal eosinophilia. Also highlighted is evidence to support both pharmacologic and nonpharmacologic treatments, including topical corticosteroids, dietary elimination therapy, and endoscopic dilation.
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Affiliation(s)
- Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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263
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Variable yield of allergy patch testing in children with eosinophilic esophagitis. J Allergy Clin Immunol 2013; 131:613. [DOI: 10.1016/j.jaci.2012.10.053] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Accepted: 10/29/2012] [Indexed: 01/07/2023]
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264
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Lucendo AJ, Arias Á, González-Cervera J, Yagüe-Compadre JL, Guagnozzi D, Angueira T, Jiménez-Contreras S, González-Castillo S, Rodríguez-Domíngez B, De Rezende LC, Tenias JM. Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease. J Allergy Clin Immunol 2013; 131:797-804. [PMID: 23375693 DOI: 10.1016/j.jaci.2012.12.664] [Citation(s) in RCA: 272] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 12/06/2012] [Accepted: 12/10/2012] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although empiric exclusion from the diet of the 6 food groups most likely to trigger allergies achieves eosinophilic esophagitis (EoE) remission in children, data on its prolonged efficacy and effects on adults are lacking. OBJECTIVE We sought to evaluate the efficacy of a 6-food elimination diet in inducing and maintaining prolonged remission in patients with adult EoE. METHODS Sixty-seven consecutive patients with adult EoE were prospectively recruited and treated exclusively with a diet avoiding cereals, milk, eggs, fish/seafood, legumes/peanuts, and soy for 6 weeks. Subsequent challenge was undertaken by sequentially reintroducing all excluded single foods, followed by endoscopy and biopsies, which were developed every 6 weeks in case of response (eosinophil peak count reduction to <15/high-power field [hpf]). A food was considered a trigger for EoE and removed from the diet if pathologic eosinophilic infiltration (≥15 eosinophils/hpf) reappeared. Food-specific serum IgE measurements and skin prick tests were performed before initiating the diet. RESULTS Forty-nine (73.1%) patients exhibited significantly reduced eosinophil peak counts (<15 eosinophils/hpf) before sequential single-food reintroduction. A single offending food antigen was identified in 35.71% of patients, 2 food triggers were identified in 30.95%, and 3 or more food triggers were identified in 33.3%. Cow's milk was the most common food antigen (61.9%), followed by wheat (28.6%), eggs (26.2%), and legumes (23.8%). Prior allergy tests showed no concordance with food-reintroduction challenge results. All patients who continued to avoid the offending foods maintained histopathologic and clinical EoE remission for up to 3 years. CONCLUSIONS An empiric 6-food elimination diet effectively induced remission of active adult EoE, which was maintained for up to 3 years with individually tailored, limited exclusion diets.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain.
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265
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Gottlieb SJ, Johnston DT, Markowitz JE. A role for food allergy testing in eosinophilic esophagitis. J Allergy Clin Immunol 2013; 131:242-3. [DOI: 10.1016/j.jaci.2012.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 09/10/2012] [Indexed: 10/27/2022]
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Sicherer SH, Leung DYM. Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2012. J Allergy Clin Immunol 2012. [PMID: 23199604 DOI: 10.1016/j.jaci.2012.11.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This review highlights some of the research advances in anaphylaxis; hypersensitivity reactions to foods, drugs, and insects; and allergic skin diseases that were reported in the Journal in 2012. Studies support an increase in peanut allergy prevalence in children and exposure to the antibacterial agent triclosan and having filaggrin (FLG) loss-of-function mutations as risk factors for food sensitization. The role of specific foods in causing eosinophilic esophagitis is elucidated by several studies, and microRNA analysis is identified as a possible noninvasive disease biomarker. Studies on food allergy diagnosis emphasize the utility of component testing and the possibility of improved diagnosis through stepped approaches, epitope-binding analysis, and bioinformatics. Treatment studies of food allergy show promise for oral immunotherapy, but tolerance induction remains elusive, and additional therapies are under study. Studies on anaphylaxis suggest an important role for platelet-activating factor and its relationship to the need for prompt treatment with epinephrine. Insights on the pathophysiology and diagnosis of non-IgE-mediated drug allergy are offered, with novel data regarding the interaction of drugs with HLA molecules. Numerous studies support influenza vaccination of persons with egg allergy using modest precautions. Evidence continues to mount that there is cross-talk between skin barrier defects and immune responses in patients with atopic dermatitis. Augmentation of the skin barrier with reduction in skin inflammatory responses will likely lead to the most effective intervention in patients with this common skin disease.
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Affiliation(s)
- Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Department of Pediatrics, Mount Sinai School of Medicine, New York, NY 10029-6574, USA.
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Henderson CJ, Collins MH, Abonia JP, Putnam PE, Rothenberg ME. Reply: To PMID 22541246. J Allergy Clin Immunol 2012; 131:243-4. [PMID: 23127828 DOI: 10.1016/j.jaci.2012.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 09/10/2012] [Indexed: 01/06/2023]
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Eosinophilic esophagitis--recognition, diet and drugs. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:510-1. [PMID: 22891174 DOI: 10.1155/2012/984260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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