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Outcomes of Various Interventions in Patients with Eosinophilic Esophagitis (EE)
S246 Abstracts
951
Eosinophilic Inflammation Is Prominent In Food Proteininduced Enterocolits Syndrome, Multi-center Case-series Study. I. Nomura1,2, T. Fukuie3, Y. Ohya1,3, A. Terada3, S. Hosokawa3, N. Ohtsuka3, H. Hoshina3, M. Watanabe3, A. Isozaki3, N. Ito3, K. Ito3; 1National Center for Child Health and Development, Tokyo, Japan, 2National Hospital Organization Kanagawa Hospital, Hadano-City, Japan, 3Japanese Research Group for Neonatal, Infantile Allergic Disorders, Tokyo, Japan. RATIONALE: FPIES is non-immediate type gastrointestinal allergy affecting neonates and infants. Since 1995, incidence rate of FPIES has been elevated in Japan. Sometimes, clinical signs are non-specific and vague. Specific IgE to milk protein is not detected in many patients. Diagnosis is not easy and delay of the treatment can lead to serious complications. We performed multi-center case-series study and intended to establish up-to date recommendations for diagnosis and treatment. METHODS: Inclusion criteria were to fulfill at least 1-4 of those 5 steps for diagnosis. 1) Suspicion of FPIES based on symptoms, 2) Differential diagnosis from other disorders based on laboratory examinations, 3) Switch to therapeutic milk and resolution of the symptoms, 4) Verify body weight gain every month, 5) Challenge test to confirm diagnosis. Japanese Research Group experienced 114 patients and reviewed clinical and laboratory data. RESULTS: Mean date of the onset was 5.2 days after birth. Symptoms at onset were vomiting (35%), bloody stool (36%) and diarrhea (8%). High eosinophil count (more than 20%) in peripheral blood was seen in 50% of the patients. Stool eosinophil was seen in 69%. Lymphocyte stimulation test to milk protein was positive in 73%. Specific IgE to milk protein was detected only in 47% of the patients. CONCLUSIONS: Eosinophilic inflammation was prominent in FPIES. But still confirmative diagnosis is not easy. If suspected, change of formula is recommended not to lead serious complications. (Home page address of our recommendations for diagnosis and treatment; http://www.nch.go.jp/ imal/FPIES/FPIES_eng.htm).
952
TUESDAY
Lamina Propria and Smooth Muscle Mast Cells in Pediatric Eosinophilic Esophagitis S. S. Aceves1,2, D. Chen2, R. O. Newbury1, R. Dohil1,2, J. F. Bastian1, D. H. Broide2; 1Rady Children’s Hospital, San Diego, CA, 2University of California, San Diego, San Diego, CA. RATIONALE: Although degranulated mast cells (MC) are increased in the epithelium of pediatric eosinophilic esophagitis (EE) patients, the number of lamina propria (LP) and smooth muscle MC and their response to corticosteroids in EE remain unknown. METHODS: Using immunohistochemical stains for chymase and tryptase followed by image analysis, we have quantitated MC in the esophageal submucosa in pediatric EE patients (n 5 15) prior to and following budesonide therapy for at least 3 months. RESULTS: Tryptase positive, but not chymase positive, MC are increased in the LP of pediatric EE patients as compared to control patients (p < 0.05). Tryptase positive MCs are also increased in the smooth muscle of the muscularis mucosa of EE patients as compared with controls (p < 0.05). Following topical esophageal budesonide therapy, tryptase positive MCs are decreased in the epithelium (p < 0.01) but not in the LP, even in patients who have resolution of epithelial and LP eosinophils. Despite the decrease in epithelial tryptase positive cells, LP tryptase positive cells persisted following therapy (p 5 0.5). CONCLUSIONS: Elevated numbers of tryptase positive MC are noted in the LP and muscularis layers in EE patients. Topical corticosteroid therapy does not reduce these MC which may contribute to persistent symptoms and remodeling in EE.
J ALLERGY CLIN IMMUNOL FEBRUARY 2009
953
Food and environmental allergies in children with Eosinophilic Esophagitis V. Velazquez, C. A. Camacho, J. Irizarry, A. Mercado; Ponce School of Medicine/Hospital Episcopal San Lucas, Ponce, PR. RATIONALE: Describe demographic and clinical presentation, of children diagnosed with Eosinophilic Esophagitis (EE), report atopic characteristics and sensitization profile to food and environmental allergens. METHOD: Cross sectional study with 24 patients from 1 month to 18 years with gastrointestinal symptoms and EE confirmed by histopathology of esophageal biopsies. Evaluation of age, sex, symptoms, and atopy with patient history of allergies, skin prick test and immunoassays test for food and environmental allergens. RESULTS: 54.2% were female and 45.8% were male, median age was 7 years old. The largest group age was 5 to 10 years old (46%), most common presenting symptoms were epigastric pain,42%, abdominal pain, 33% and GER with 21%. In the group age of 0 to 4 years old, the most common presenting symptom was vomiting. 83% presented sensitization to at least one allergen. 35% of the allergies were to environmental allergens, most common dust mite. Food allergies were present in 15% of the patients; allergies to egg, wheat and soybean (12% each one) were the most prevalent. CONCLUSIONS: This is the first study describing children with EE in Puerto Rico. Slight female to male predominance. Group age frequency) was compatible with reported literature. Most common presenting symptom was epigastric pain and vomiting. Although food allergens are the proposed offending agents involved in the pathogenesis of EE, only 20% of the pediatric patients with EE in our study presented any food allergy. Environmental allergies were most prevalent. 17% of our patients were not allergic to the used allergy testing.
954
Outcomes of Various Interventions in Patients with Eosinophilic Esophagitis (EE) C. J. Ramos-Romey, G. Ghaffari; Penn State Hershey Medical Center, Hershey, PA. RATIONALE: Eosinophilic esophagitis (EE) which is characterized by eosinophilic infiltration of the esophagus is considered an allergic disorder. Optimal therapy for this emerging condition has yet to be determined. It has been proposed that food avoidance may improve the symptoms and reduce eosinophilic inflammation in EE. The purpose of this study is to evaluate the patient’s response to various treatments, to identify the most effective interventions. METHODS: Ten patients previously evaluated in our allergy clinic, with biopsy confirmed EE were contacted for a telephone interview. Clinical information regarding previous and current symptoms related to EE, dietary modifications and pharmacotherapy, as well as response to each intervention was collected using a disease-specific questionnaire. IRB approval was obtained. RESULTS: Symptoms improved in seven patients (70%) with food avoidance guided by the results of food skin prick testing, patch testing and serum specific IgE. One patient (10%) did not present any clinical improvement in symptoms but biopsy results improved with food avoidance. Symptoms recurred in all 7 patients who had responded to elimination diet upon re-exposure to the culprit foods. Two patients (20%) did not have any evidence of sensitization to foods, but tested positive to environmental allergens. Their symptoms improved with allergen avoidance and swallowed fluticasone therapy. In one of these patients further improvement of EE symptoms was achieved after initiation of immunotherapy for allergic rhinitis. CONCLUSIONS: Patients with EE should undergo immediate and delayed hypersensitivity testing, since symptoms and quality of life improve with avoidance of foods to which they are sensitized.
951
Eosinophilic Inflammation Is Prominent In Food Proteininduced Enterocolits Syndrome, Multi-center Case-series Study. I. Nomura1,2, T. Fukuie3, Y. Ohya1,3, A. Terada3, S. Hosokawa3, N. Ohtsuka3, H. Hoshina3, M. Watanabe3, A. Isozaki3, N. Ito3, K. Ito3; 1National Center for Child Health and Development, Tokyo, Japan, 2National Hospital Organization Kanagawa Hospital, Hadano-City, Japan, 3Japanese Research Group for Neonatal, Infantile Allergic Disorders, Tokyo, Japan. RATIONALE: FPIES is non-immediate type gastrointestinal allergy affecting neonates and infants. Since 1995, incidence rate of FPIES has been elevated in Japan. Sometimes, clinical signs are non-specific and vague. Specific IgE to milk protein is not detected in many patients. Diagnosis is not easy and delay of the treatment can lead to serious complications. We performed multi-center case-series study and intended to establish up-to date recommendations for diagnosis and treatment. METHODS: Inclusion criteria were to fulfill at least 1-4 of those 5 steps for diagnosis. 1) Suspicion of FPIES based on symptoms, 2) Differential diagnosis from other disorders based on laboratory examinations, 3) Switch to therapeutic milk and resolution of the symptoms, 4) Verify body weight gain every month, 5) Challenge test to confirm diagnosis. Japanese Research Group experienced 114 patients and reviewed clinical and laboratory data. RESULTS: Mean date of the onset was 5.2 days after birth. Symptoms at onset were vomiting (35%), bloody stool (36%) and diarrhea (8%). High eosinophil count (more than 20%) in peripheral blood was seen in 50% of the patients. Stool eosinophil was seen in 69%. Lymphocyte stimulation test to milk protein was positive in 73%. Specific IgE to milk protein was detected only in 47% of the patients. CONCLUSIONS: Eosinophilic inflammation was prominent in FPIES. But still confirmative diagnosis is not easy. If suspected, change of formula is recommended not to lead serious complications. (Home page address of our recommendations for diagnosis and treatment; http://www.nch.go.jp/ imal/FPIES/FPIES_eng.htm).
952
TUESDAY
Lamina Propria and Smooth Muscle Mast Cells in Pediatric Eosinophilic Esophagitis S. S. Aceves1,2, D. Chen2, R. O. Newbury1, R. Dohil1,2, J. F. Bastian1, D. H. Broide2; 1Rady Children’s Hospital, San Diego, CA, 2University of California, San Diego, San Diego, CA. RATIONALE: Although degranulated mast cells (MC) are increased in the epithelium of pediatric eosinophilic esophagitis (EE) patients, the number of lamina propria (LP) and smooth muscle MC and their response to corticosteroids in EE remain unknown. METHODS: Using immunohistochemical stains for chymase and tryptase followed by image analysis, we have quantitated MC in the esophageal submucosa in pediatric EE patients (n 5 15) prior to and following budesonide therapy for at least 3 months. RESULTS: Tryptase positive, but not chymase positive, MC are increased in the LP of pediatric EE patients as compared to control patients (p < 0.05). Tryptase positive MCs are also increased in the smooth muscle of the muscularis mucosa of EE patients as compared with controls (p < 0.05). Following topical esophageal budesonide therapy, tryptase positive MCs are decreased in the epithelium (p < 0.01) but not in the LP, even in patients who have resolution of epithelial and LP eosinophils. Despite the decrease in epithelial tryptase positive cells, LP tryptase positive cells persisted following therapy (p 5 0.5). CONCLUSIONS: Elevated numbers of tryptase positive MC are noted in the LP and muscularis layers in EE patients. Topical corticosteroid therapy does not reduce these MC which may contribute to persistent symptoms and remodeling in EE.
J ALLERGY CLIN IMMUNOL FEBRUARY 2009
953
Food and environmental allergies in children with Eosinophilic Esophagitis V. Velazquez, C. A. Camacho, J. Irizarry, A. Mercado; Ponce School of Medicine/Hospital Episcopal San Lucas, Ponce, PR. RATIONALE: Describe demographic and clinical presentation, of children diagnosed with Eosinophilic Esophagitis (EE), report atopic characteristics and sensitization profile to food and environmental allergens. METHOD: Cross sectional study with 24 patients from 1 month to 18 years with gastrointestinal symptoms and EE confirmed by histopathology of esophageal biopsies. Evaluation of age, sex, symptoms, and atopy with patient history of allergies, skin prick test and immunoassays test for food and environmental allergens. RESULTS: 54.2% were female and 45.8% were male, median age was 7 years old. The largest group age was 5 to 10 years old (46%), most common presenting symptoms were epigastric pain,42%, abdominal pain, 33% and GER with 21%. In the group age of 0 to 4 years old, the most common presenting symptom was vomiting. 83% presented sensitization to at least one allergen. 35% of the allergies were to environmental allergens, most common dust mite. Food allergies were present in 15% of the patients; allergies to egg, wheat and soybean (12% each one) were the most prevalent. CONCLUSIONS: This is the first study describing children with EE in Puerto Rico. Slight female to male predominance. Group age frequency) was compatible with reported literature. Most common presenting symptom was epigastric pain and vomiting. Although food allergens are the proposed offending agents involved in the pathogenesis of EE, only 20% of the pediatric patients with EE in our study presented any food allergy. Environmental allergies were most prevalent. 17% of our patients were not allergic to the used allergy testing.
954
Outcomes of Various Interventions in Patients with Eosinophilic Esophagitis (EE) C. J. Ramos-Romey, G. Ghaffari; Penn State Hershey Medical Center, Hershey, PA. RATIONALE: Eosinophilic esophagitis (EE) which is characterized by eosinophilic infiltration of the esophagus is considered an allergic disorder. Optimal therapy for this emerging condition has yet to be determined. It has been proposed that food avoidance may improve the symptoms and reduce eosinophilic inflammation in EE. The purpose of this study is to evaluate the patient’s response to various treatments, to identify the most effective interventions. METHODS: Ten patients previously evaluated in our allergy clinic, with biopsy confirmed EE were contacted for a telephone interview. Clinical information regarding previous and current symptoms related to EE, dietary modifications and pharmacotherapy, as well as response to each intervention was collected using a disease-specific questionnaire. IRB approval was obtained. RESULTS: Symptoms improved in seven patients (70%) with food avoidance guided by the results of food skin prick testing, patch testing and serum specific IgE. One patient (10%) did not present any clinical improvement in symptoms but biopsy results improved with food avoidance. Symptoms recurred in all 7 patients who had responded to elimination diet upon re-exposure to the culprit foods. Two patients (20%) did not have any evidence of sensitization to foods, but tested positive to environmental allergens. Their symptoms improved with allergen avoidance and swallowed fluticasone therapy. In one of these patients further improvement of EE symptoms was achieved after initiation of immunotherapy for allergic rhinitis. CONCLUSIONS: Patients with EE should undergo immediate and delayed hypersensitivity testing, since symptoms and quality of life improve with avoidance of foods to which they are sensitized.