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de Oliveira FD, Costa RC, de Santana Sato EDB, Khalil SM, Meine GC. Efficacy and Safety of Monoclonal Antibodies for the Treatment of Eosinophilic Esophagitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Dig Dis Sci 2024:10.1007/s10620-024-08413-w. [PMID: 38709421 DOI: 10.1007/s10620-024-08413-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/27/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND AND AIMS Monoclonal antibodies (MAbs) have clinical benefits for treating several atopic diseases. However, consensus on its use for eosinophilic esophagitis (EoE) is lacking. The present meta-analysis aimed to compare the efficacy and safety of MAbs versus placebo for treating EoE. METHODS We searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs). The primary outcomes were changes in peak esophageal eosinophils count/high power field (HPF) and mean esophageal eosinophils count/HPF. The secondary outcomes were changes in the EoE-Histology Scoring System (EoE-HSS), Endoscopic Reference Score (EREFS), dysphagia score, and adverse events (AEs). We compared binary outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD) or standardized mean difference (SMD), with 95% confidence interval (CI). Considering the diversity of mechanistic properties of MAbs, a pre-specified subgroup analysis by MAb mechanism of action was performed for all outcomes, provided that at least two studies were in each subgroup. Heterogeneity was assessed using Cochran's Q test and I2 statistics. RESULTS 6 RCTs were included (533 patients). Compared to placebo, MAbs led to a significant reduction in peak esophageal eosinophils count/HPF (MD -0.78; CI 95% -0.87, -0.6801) and mean esophageal eosinophils count/HPF (SMD -0.79; CI 95% -1.5, -0.08). Moreover, MAbs significantly reduced EoE-HSS scores (grade score: SMD -9.31; 95% CI -13.95, -4.6701; stage score: SMD -10.18; 95% CI -15.06, -5.31), EREFS (SMD -5.95; CI 95% -9.19, -2.71) and dysphagia score (SMD -1.79; CI 95% -3.36, -0.23) without increasing AEs compared to placebo. Among those MAbs whose mechanism of action includes the blockage of the receptor for IL-13 (Dupilumab, QAX576, and RPC4046), the scores of EoE-HSS grade, EoE-HSS stage, EREFS, and dysphagia were significantly reduced, and they presented a similar risk of overall and serious AEs compared to placebo. CONCLUSION MAbs seem effective and safe in reducing esophageal eosinophil infiltrate, EoE-HSS score, EREFS score, and dysphagia symptoms in patients with EoE. However, further evidence is needed to establish its place in EoE management.
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Affiliation(s)
| | | | | | | | - Gilmara Coelho Meine
- Division of Gastroenterology, Internal Medicine Department, Instituto de Ciências da Saúde - ICS, Universidade Feevale, Novo Hamburgo, Brazil.
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2
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Bauer M, Nguyen N, Liacouras CA. Clinical Evaluation of the Child with Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:157-171. [PMID: 38575215 DOI: 10.1016/j.iac.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
The diagnosis of eosinophilic esophagitis (EoE) is based on clinical symptoms of esophageal dysfunction and eosinophil predominant esophageal inflammation. Clinical symptoms in children with EoE vary based on age and may be nonspecific. EoE has a male predominance with the majority having comorbid atopic disorders. At present, treatment options include medications (proton pump inhibition, swallowed topical steroids), dietary therapy or biologic therapy (dupilumab, approved for those ≥12 years of age). Outside of EoE in the context of oral immunotherapy, EoE is typically chronic requiring lifelong therapy. Long-term complications including feeding difficulties, malnutrition, and fibrostenotic disease.
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Affiliation(s)
- Maureen Bauer
- Department of Pediatric Allergy & Immunology, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 518, Aurora, CO 80045, USA.
| | - Nathalie Nguyen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Gastrointestinal Eosinophilic Diseases Program, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 518, Aurora, CO 80045, USA
| | - Chris A Liacouras
- Department of Gastroenterology, Hepatology and Nutrition, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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3
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Kimura M, Ando T, Kume Y, Fukase S, Matsuzawa M, Kashiwagi K, Izawa K, Kaitani A, Nakano N, Maeda K, Ogawa H, Okumura K, Nakao S, Murakami A, Ebihara N, Kitaura J. A nerve-goblet cell association promotes allergic conjunctivitis through rapid antigen passage. JCI Insight 2023; 8:e168596. [PMID: 37819721 PMCID: PMC10721269 DOI: 10.1172/jci.insight.168596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 09/20/2023] [Indexed: 10/13/2023] Open
Abstract
The penetration of allergens through the epithelial layer is the initial step in the development of allergic conjunctivitis. Although pollinosis patients manifest symptoms within minutes after pollen exposure, the mechanisms of the rapid transport of the allergens remain unclear. In the present study, we found that the instillation of pollen shells rapidly induces a large number of goblet cell-associated antigen passages (GAPs) in the conjunctiva. Antigen acquisition by stromal cells, including macrophages and CD11b+ dendritic cells, correlated with surface GAP formation. Furthermore, a substantial amount of antigen was transported to the stroma during the first 10 minutes of pollen exposure, which was sufficient for the full induction of an allergic conjunctivitis mouse model. This inducible, rapid GAP formation and antigen acquisition were suppressed by topical lidocaine or trigeminal nerve ablation, indicating that the sensory nervous system plays an essential role. Interestingly, pollen shell-stimulated GAP formation was not suppressed by topical atropine, suggesting that the conjunctival GAPs and intestinal GAPs are differentially regulated. These results identify pollen shell-induced GAP as a therapeutic target for allergic conjunctivitis.
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Affiliation(s)
- Meiko Kimura
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Ophthalmology, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
- Department of Ophthalmology
| | - Tomoaki Ando
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Yasuharu Kume
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Ophthalmology, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
- Department of Ophthalmology
| | - Saaya Fukase
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Ophthalmology, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
- Department of Ophthalmology
| | - Moe Matsuzawa
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Ophthalmology, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
- Department of Ophthalmology
| | - Kosuke Kashiwagi
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Pediatrics and Adolescent Medicine, and
| | - Kumi Izawa
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Ayako Kaitani
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Nobuhiro Nakano
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Keiko Maeda
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Hideoki Ogawa
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Ko Okumura
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | | | | | - Nobuyuki Ebihara
- Department of Ophthalmology, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
- Department of Ophthalmology
| | - Jiro Kitaura
- Atopy Research Center, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Science of Allergy and Inflammation, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
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4
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Guarnieri KM, Saba NK, Schwartz JT, Devonshire AL, Bufford J, Casale TB, Rothenberg ME, Andorf S. Food Allergy Characteristics Associated With Coexisting Eosinophilic Esophagitis in FARE Registry Participants. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1509-1521.e6. [PMID: 36801492 PMCID: PMC10164686 DOI: 10.1016/j.jaip.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) can coexist in individuals with food allergy. OBJECTIVE To evaluate the characteristics of food-allergic patients with and without coexisting EoE using a large food allergy patient registry. METHODS Data were derived from 2 Food Allergy Research & Education, Inc, Patient Registry surveys. A series of multivariable regression models were used to evaluate associations between demographic, comorbidity, and food allergy characteristics and the likelihood of reporting EoE. RESULTS Five percent (n = 309) of registry participants (n = 6074; ages <1 year->80 years, mean, 20.20 ± 15.37 years) reported having EoE. The odds of having EoE were significantly greater in male participants (adjusted odds ratio [aOR], 1.3; 95% CI, 1.04-1.72) and those with comorbid asthma (aOR, 2.0; 95% CI, 1.55-2.49), allergic rhinitis (aOR, 1.8; 95% CI, 1.37-2.22), oral allergy syndrome (aOR, 2.8; 95% CI, 2.09-3.70), food protein-induced enterocolitis syndrome (aOR, 2.5; 95% CI, 1.34-4.84), and hyper-IgE syndrome (aOR, 7.6; 95% CI, 2.93-19.92), though not atopic dermatitis (aOR, 1.3; 95% CI, 0.99-1.59), when adjusting for demographics (sex, age, race, ethnicity, and geographic location). Those with a greater number of food allergies (aOR, 1.3; 95% CI, 1.23-1.32), more frequent food-related allergic reactions (aOR, 1.2; 95% CI, 1.11-1.24), previous anaphylaxis (aOR, 1.5; 95% CI, 1.15-1.83), and health care utilization for food-related allergic reactions (aOR, 1.3; 95% CI, 1.01-1.67)-specifically intensive care unit admission (aOR, 1.2; 95% CI, 1.07-1.33)-were more likely to have EoE after controlling for demographics. However, no significant difference in ever using epinephrine for food-related allergic reactions was detected. CONCLUSIONS These self-reported data showed that coexisting EoE is associated with an increased number of food allergies, food-related allergic reactions per year, and measures of reaction severity, calling attention to the likely increased health care needs of food-allergic patients with EoE.
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Affiliation(s)
- Katharine M Guarnieri
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nicholas K Saba
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Justin T Schwartz
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashley L Devonshire
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Thomas B Casale
- Food Allergy Research & Education, McLean, Va; Division of Allergy and Immunology, University of South Florida, Tampa, Fla
| | - Marc E Rothenberg
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sandra Andorf
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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5
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Fukase S, Ando T, Matsuzawa M, Kimura M, Sone Y, Izawa K, Kaitani A, Kamei A, Kojima M, Nakano N, Maeda K, Shimizu T, Ogawa H, Okumura K, Nishiyama M, Murakami A, Ebihara N, Kitaura J. Pollen shells and soluble factors play non-redundant roles in the development of allergic conjunctivitis in mice. Ocul Surf 2021; 22:152-162. [PMID: 34428578 DOI: 10.1016/j.jtos.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 08/12/2021] [Accepted: 08/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE We aimed to clarify the role of particulate allergen exposure to the conjunctiva in the development of allergic conjunctivitis. METHODS We administered ragweed pollen suspension, pollen extract, pollen shell, particulate air pollutants, and their combinations to the mouse conjunctiva five days a week without prior sensitization. Clinical signs were scored. Histological changes, cellular infiltrations, mRNA expressions, lymph node cell recall responses, and serum immunoglobulin levels were assessed. Immune cell-depleting antibodies and ST2 knockout mice were used to investigate the cellular and molecular requirements. RESULTS Pollen suspension, but not the extract or shell alone, induced robust eosinophilic conjunctivitis, accompanied by a proliferative response of epithelial cells. A combination of pollen extract and shell completely restored eosinophil accumulation. In addition, eosinophilic conjunctivitis was induced by a mixture of particulate air pollutants and pollen extract. Mechanistically, eosinophil accumulation was ameliorated by deficiency of the IL-33 receptor ST2 and abolished by depleting CD4+ T cells. Pollen shells, but not the extract, induced IL-33 release from conjunctival epithelial cells in vivo. CONCLUSIONS Our results indicate the non-redundant roles for the allergens' particulate properties and soluble factors in the development of allergic conjunctivitis.
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Affiliation(s)
- Saaya Fukase
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan; Department of Ophthalmology, Juntendo University Urayasu Hospital, Urayasu, Chiba, 279-0021, Japan; Department of Ophthalmology, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Tomoaki Ando
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan.
| | - Moe Matsuzawa
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan; Department of Ophthalmology, Juntendo University Urayasu Hospital, Urayasu, Chiba, 279-0021, Japan; Department of Ophthalmology, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Meiko Kimura
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan; Department of Ophthalmology, Juntendo University Urayasu Hospital, Urayasu, Chiba, 279-0021, Japan; Department of Ophthalmology, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Yusuke Sone
- Laboratory of Cell Biotechnology, Biotechnology Research Center, The University of Tokyo, Tokyo, 113-8657, Japan
| | - Kumi Izawa
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Ayako Kaitani
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Anna Kamei
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan; Department of Science of Allergy and Inflammation, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Mayuki Kojima
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan; Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Nobuhiro Nakano
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Keiko Maeda
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan; Department of Immunological Diagnosis, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Toshiaki Shimizu
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan; Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Hideoki Ogawa
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Ko Okumura
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Makoto Nishiyama
- Laboratory of Cell Biotechnology, Biotechnology Research Center, The University of Tokyo, Tokyo, 113-8657, Japan
| | - Akira Murakami
- Department of Ophthalmology, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Nobuyuki Ebihara
- Department of Ophthalmology, Juntendo University Urayasu Hospital, Urayasu, Chiba, 279-0021, Japan; Department of Ophthalmology, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | - Jiro Kitaura
- Atopy (Allergy) Research Center, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan; Department of Science of Allergy and Inflammation, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan.
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6
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Malone V, Sheahan K. Novel and rare forms of oesophagitis. Histopathology 2020; 78:4-17. [PMID: 33382498 DOI: 10.1111/his.14284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/09/2020] [Accepted: 10/20/2020] [Indexed: 12/11/2022]
Abstract
Our understanding of inflammatory diseases of the gastrointestinal tract, including those of the oesophagus, has expanded in recent years. Once attributed almost exclusively to gastro-oesophageal reflux disease or infection, it is now recognised that oesophagitis may occur due to a variety of distinct disease entities. Many of these conditions cause debilitating and persistent symptoms, impacting upon quality of life and necessitating ongoing surveillance and treatment. This review will consider the clinical, endoscopic and histopathological features of these novel and rare forms of oesophagitis.
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Affiliation(s)
- Victoria Malone
- Department of Histopathology, St Vincent's University Hospital, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Kieran Sheahan
- Department of Histopathology, St Vincent's University Hospital, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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7
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Trivedi A, Katelaris C. Presentation, diagnosis, and the role of subcutaneous and sublingual immunotherapy in the management of ocular allergy. Clin Exp Optom 2020; 104:334-349. [PMID: 32944983 DOI: 10.1111/cxo.13129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Allergic eye disease or ocular allergy is a debilitating condition with a significant impact on quality of life and productivity. As atopy continues to be on the rise, primary care providers are likely to encounter increasing numbers of patients with allergic eye disease. This review outlines the classification and pathophysiology of allergic eye disease and its clinical presentation. This paper does not detail traditional first-line therapies of allergic eye disease but describes the interdisciplinary management between the eye-care provider and allergist. It is recommended that patients with ongoing signs and symptoms of ocular allergy despite first-line therapies be referred for allergen immunotherapy, as it is highly effective for treatment of allergic eye disease. Through induction of immune tolerance, allergen immunotherapy is a disease-modifying therapy that can result in long-term improvement of ocular allergy. A thorough literature review was conducted on the efficacy and safety of allergen immunotherapy, including subcutaneous immunotherapy and sublingual immunotherapy, and its role in allergic eye disease.
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Affiliation(s)
- Amruta Trivedi
- Immunology Department, Campbelltown Hospital, Sydney, Australia.,Department of Medicine, Campbelltown Hospital, Sydney, Australia
| | - Constance Katelaris
- Immunology Department, Campbelltown Hospital, Sydney, Australia.,Department of Medicine, Campbelltown Hospital, Sydney, Australia
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8
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Bakulina NV, Simanenkov VI, Vorobyev SL, Tikhonov SV, Lishchuk NB, Bakulin IG. The eosinophilic esophagitis and IgG4-related disease involving the esophagus. TERAPEVT ARKH 2020; 92:100-107. [DOI: 10.26442/00403660.2020.08.000792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Indexed: 11/22/2022]
Abstract
The study of eosinophilic esophagitis has become a dynamic field with an evolving understanding of the pathogenesis, diagnosis, and treatment. Immunoglobulin G4 (IgG4)-related disease exhibits systemic involvement but very rarely involves the esophagus. The article presents a clinical case: the history of ulcer and stricture of the esophagus in a young man of 17 years. The patient was finally diagnosed with IgG4-related and eosinophilic esophagitis and showed a good response to corticosteroid therapy. We herein report a rare case of dysphagia associated with IgG4-related disease and eosinophilic. We presented a review of modern data on the relationship of eosinophilic esophagitis and pathological IgG4-response.
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9
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Lu CY, Hsieh MS, Wei KC, Ezmerli M, Kuo CH, Chen W. Gastrointestinal involvement of primary skin diseases. J Eur Acad Dermatol Venereol 2020; 34:2766-2774. [PMID: 32455473 DOI: 10.1111/jdv.16676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/11/2020] [Indexed: 12/14/2022]
Abstract
Less is known about gastrointestinal (GI) involvement of primary skin diseases due to the difference in embryology, histology, microbiology and physiology between integument and alimentary tract. Oesophagus, following the oropharyngeal mucosa, is the most common GI segment affected by primary skin diseases, especially by eosinophilic oesophagitis, lichen planus and autoimmune bullous dermatoses like pemphigus vulgaris, mucosal membrane pemphigoid and epidermolysis bullosa acquisita. Eosinophilic oesophagitis is an emerging chronic atopic disease with oesophageal dysfunction as the typical presentation, and oesophageal narrowing, rings and stricture as late complications. Oesophageal lichen planus mainly involves the proximal to mid-oesophagus in elderly aged women with long-term oral mucosal lesions. In acute attack of pemphigus vulgaris, oesophageal involvement is not uncommon but often neglected and may cause sloughing oesophagitis (oesophagitis dissecans superficialis) with acute GI bleeding in rare cases. GI manifestation of hereditary bradykininergic angio-oedema with colicky acute abdomen mostly affects small intestine, usually in the absence of pruritus or urticaria, and is more severe and long-lasting than the acquired histaminergic form. Strong evidence supports association between inflammatory bowel disease, especially Crohn disease, and hidradenitis suppurativa/acne inversa. Patients with vitiligo need surveillance of autoimmune liver disease, autoimmune atrophic gastritis or coeliac disease when corresponding symptoms become suspect. Melanoma is the most common primary tumour metastatic to the GI tract, with small intestine predominantly targeted. Gastrointestinal involvement is not uncommon in disseminated mycosis fungoides. Extramammary Paget's disease is an intraepidermal adenocarcinoma of controversial origin, and a high association between the anogenital occurrence and colorectal adenocarcinoma has been reported. As GI tract is the largest organ system with multidimensional functions, dermatologists in daily practice should be aware of the gastrointestinal morbidities related to primary skin diseases for an early diagnosis and treatment.
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Affiliation(s)
- C-Y Lu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - M-S Hsieh
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - K-C Wei
- Department of Dermatology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - M Ezmerli
- Department of Dermatology, Faculty of Medicine in Rabigh, Kingdom of Saudi Arabia, King Abdulaziz University, Jeddah, Saudi Arabia
| | - C-H Kuo
- Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - W Chen
- Center for Research & Development, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan.,Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
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10
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Dupuis P, Prokopich CL, Hynes A, Kim H. A contemporary look at allergic conjunctivitis. Allergy Asthma Clin Immunol 2020; 16:5. [PMID: 31993069 PMCID: PMC6975089 DOI: 10.1186/s13223-020-0403-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/09/2020] [Indexed: 01/16/2023] Open
Abstract
Allergic eye disease is common, yet often overlooked in North America. In the U.S., up to 40% of the population is deemed to be affected and this number is growing. Symptoms and signs of ocular allergy can lead to decreased productivity and negatively impact quality of life (QoL). Various treatment options exist to achieve symptom control. For allergic conjunctivitis, ophthalmic agents include antihistamines, mast cell stabilizers, dual-activity agents, nonsteroidal anti-inflammatory drugs (NSAIDs), steroids and some off-label treatments. Immunotherapy is recommended as a therapeutic option. This review provides a summary of the forms of ocular allergies, with a focus on symptoms and signs, impact on QoL, physical examination, diagnosis and therapeutic options of allergic conjunctivitis. Through multidisciplinary collaborations, a simplified algorithm for the treatment of allergic conjunctivitis is proposed for Canadian clinical practice.
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Affiliation(s)
- Pascale Dupuis
- 1Division of Clinical Immunology and Allergy, Department of Medicine, St. Joseph's Hospital, Western University, Room B3-102, 268 Grosvenor Street, London, ON N6A 4V2 Canada
| | - C Lisa Prokopich
- 2School of Optometry & Vision Science, University of Waterloo, 200 Columbia St W., Waterloo, ON N2L 3G1 Canada
| | | | - Harold Kim
- 1Division of Clinical Immunology and Allergy, Department of Medicine, St. Joseph's Hospital, Western University, Room B3-102, 268 Grosvenor Street, London, ON N6A 4V2 Canada.,4Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University Health Sciences Centre, 1280 Main St. W., Hamilton, ON L8S 4K1 Canada
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11
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Vinit C, Dieme A, Courbage S, Dehaine C, Dufeu C, Jacquemot S, Lajus M, Montigny L, Payen E, Yang D, Dupont C. Eosinophilic esophagitis: Pathophysiology, diagnosis, and management. Arch Pediatr 2019; 26:182-190. [DOI: 10.1016/j.arcped.2019.02.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 12/10/2018] [Accepted: 02/03/2019] [Indexed: 12/31/2022]
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12
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Basharat U, Schraff S, Stevens LM, Clarke PY, Kang P, Woodward J, Schroeder SR, Rao A, Page N, Williams DI. Deep interarytenoid notch in young children managed with systematic thickener wean and injection laryngoplasty. Int J Pediatr Otorhinolaryngol 2019; 118:115-119. [PMID: 30611096 DOI: 10.1016/j.ijporl.2018.12.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 12/22/2018] [Accepted: 12/23/2018] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Deep interarytenoid notch (DIN) is a congenital variation of the larynx often associated with dysphagia and aspiration (DA) in young children. Feeding therapy with thickeners and surgical management with injection larygoplasty (IL) are used with various efficacies. Thickeners address the functional domain and IL addresses the anatomical domain of treatment. Our objective was to evaluate DIN patients managed with both interventions. METHODS We conducted a retrospective pilot descriptive study of DIN patients with DA aged 1-3 years receiving thickeners and IL. Patients received a systematic weekly reduction of thickeners, referred to as the Thickener Weaning Protocol (TWP), based on clinical signs and symptoms of DA. The outcomes were assessed by the rate of thickener level reduction and DA-related sign/symptom frequency achieved at 6 months post-treatment. RESULTS Thirteen patients with DIN associated DA were analyzed. The TWP was initiated within 2 months in 77% of patients, and within 4 months in 100% of patients. Thickener scores improved from an average of 5.76 (3/4 honey) to 2.15 (thin) (p = 0.001). DA-related signs/symptoms frequency improved from an average of 3.3 to 0.84 (p = 0.05). CONCLUSIONS These findings suggest that treatment of DIN associated DA with a combination of thickeners and IL results in significant clinical improvements in young children.
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Affiliation(s)
| | - Scott Schraff
- Arizona Otolaryngology Consultants, Phoenix, AZ, USA
| | - Lindsay M Stevens
- Department of Rehabilitation, Aerodigestive Program at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Pamela Y Clarke
- Department of Rehabilitation, Aerodigestive Program at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Paul Kang
- Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Phoenix, AZ, USA
| | - Jim Woodward
- Department of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Shauna R Schroeder
- Department of Gastroenterology, Aerodigestive Program at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Aparna Rao
- Department of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Nathan Page
- Department of Otolaryngology, Aerodigestive Program at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Dana I Williams
- Department of Gastroenterology, Aerodigestive Program at Phoenix Children's Hospital, Phoenix, AZ, USA
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13
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Sherrill JD, Kc K, Wang X, Wen T, Chamberlin A, Stucke EM, Collins MH, Abonia JP, Peng Y, Wu Q, Putnam PE, Dexheimer PJ, Aronow BJ, Kottyan LC, Kaufman KM, Harley JB, Huang T, Rothenberg ME. Whole-exome sequencing uncovers oxidoreductases DHTKD1 and OGDHL as linkers between mitochondrial dysfunction and eosinophilic esophagitis. JCI Insight 2018; 3:99922. [PMID: 29669943 DOI: 10.1172/jci.insight.99922] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/14/2018] [Indexed: 12/20/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is an allergic inflammatory esophageal disorder with a complex underlying genetic etiology often associated with other comorbidities. Using whole-exome sequencing (WES) of 63 patients with EoE and 60 unaffected family members and family-based trio analysis, we sought to uncover rare coding variants. WES analysis identified 5 rare, damaging variants in dehydrogenase E1 and transketolase domain-containing 1 (DHTKD1). Rare variant burden analysis revealed an overabundance of putative, potentially damaging DHTKD1 mutations in EoE (P = 0.01). Interestingly, we also identified 7 variants in the DHTKD1 homolog oxoglutarate dehydrogenase-like (OGDHL). Using shRNA-transduced esophageal epithelial cells and/or patient fibroblasts, we further showed that disruption of normal DHTKD1 or OGDHL expression blunts mitochondrial function. Finally, we demonstrated that the loss of DHTKD1 expression increased ROS production and induced the expression of viperin, a gene previously shown to be involved in production of Th2 cytokines in T cells. Viperin had increased expression in esophageal biopsies of EoE patients compared with control individuals and was upregulated by IL-13 in esophageal epithelial cells. These data identify a series of rare genetic variants implicating DHTKD1 and OGDHL in the genetic etiology of EoE and underscore a potential pathogenic role for mitochondrial dysfunction in EoE.
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Affiliation(s)
| | - Kiran Kc
- Division of Allergy and Immunology and
| | - Xinjian Wang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center (CCHMC), Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ting Wen
- Division of Allergy and Immunology and
| | - Adam Chamberlin
- Clinical Genomics, Ambry Genetics, Aliso Viejo, California, USA
| | | | | | | | - Yanyan Peng
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center (CCHMC), Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Qiang Wu
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center (CCHMC), Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | | | | | - Leah C Kottyan
- Center for Autoimmune Genomics and Etiology, CCHMC, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kenneth M Kaufman
- Center for Autoimmune Genomics and Etiology, CCHMC, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,US Department of Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - John B Harley
- Center for Autoimmune Genomics and Etiology, CCHMC, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,US Department of Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Taosheng Huang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center (CCHMC), Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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14
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Miglani A, Schraff S, Clarke PY, Basharat U, Woodward P, Kang P, Stevens L, Woodward J, Williams H, Williams DI. An Aerodigestive Approach to Laryngeal Clefts and Dysphagia Using Injection Laryngoplasty in Young Children. Curr Gastroenterol Rep 2017; 19:60. [PMID: 29105033 DOI: 10.1007/s11894-017-0599-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE OF REVIEW Our objective is to summarize the presentation, diagnosis, and management of mild laryngeal clefts in children. We focus on deep interarytenoid notches (DIN), a subclassification of type 1 laryngeal clefts (LC1), and review the literature and our multidisciplinary experience utilizing injection laryngoplasty (IL). RECENT FINDINGS DIN is a mild form of LC1 and is considered a normal anatomical variant. Recent cohort studies demonstrate IL to be a safe, low-risk, and efficacious treatment of LC1, but few studies focus on DIN. We present results from two aerodigestive clinic (ADC) pilot studies at our institution, in patients 1-3 years old, with DIN-related dysphagia and aspiration (DA). Feeding, respiratory-related symptom scores, and aspiration/penetration assessed on modified barium swallow (MBS) significantly improved following combined IL and feeding therapy using a thickener weaning protocol (TWP). Subgroup analysis reveals combined IL and TWP to be particularly effective in patients with severe baseline DA. Multidisciplinary aerodigestive evaluation and management with IL and feeding therapy focused on weaning levels of thickener is emerging as a novel and effective approach for treatment of DIN-related DA in young children. Further comparative, prospective trials investigating effects of IL and feeding therapy are required to validate results.
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Affiliation(s)
- Amar Miglani
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Scott Schraff
- Arizona Otolaryngology Consultants, Phoenix, AZ, USA
| | - Pamela Y Clarke
- Department of Gastroenterology, Aerodigestive Program, Phoenix Children's Hospital, Phoenix, AZ, USA
| | | | - Peter Woodward
- Department of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Paul Kang
- Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Phoenix, AZ, USA
| | - Lindsay Stevens
- Department of Gastroenterology, Aerodigestive Program, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Jim Woodward
- Department of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Howard Williams
- Department of Anesthesiology, Valley Anesthesia and Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Dana I Williams
- Department of Gastroenterology, Aerodigestive Program, Phoenix Children's Hospital, Phoenix, AZ, USA.
- Division of Pediatric Gastroenterology, Phoenix Children's Hospital, 1919 E. Thomas Rd., Phoenix, AZ, 85016, USA.
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15
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Muir AB, Benitez AJ, Dods K, Spergel JM, Fillon SA. Microbiome and its impact on gastrointestinal atopy. Allergy 2016; 71:1256-63. [PMID: 27240281 DOI: 10.1111/all.12943] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2016] [Indexed: 01/01/2023]
Abstract
The prevalence of allergic conditions has continuously increased in the last few decades in Westernized countries. A dysbiotic gut microbiome may play an important role in the development of allergic diseases. Genetic, environmental, and dietary factors may alter the commensal microbiota leading to inflammatory dysregulation of homeostasis. Murine and human studies have begun to elucidate the role of the microbiota in the pathogenesis of atopic diseases including asthma, atopic dermatitis, and food allergies. However, the role of the microbiome in most eosinophilic gastrointestinal diseases (EGIDs) is not yet known. This review provides an overview of what is currently known about the development of tolerance from both molecular and clinical standpoints. We also look at the gut-specific microbiome and its role in atopic conditions with the hope of applying this knowledge to the understanding, prevention, and treatment of EGIDs, particularly EoE.
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Affiliation(s)
- A. B. Muir
- Division of Gastroenterology, Hepatology, and Nutrition; The Children's Hospital of Philadelphia; Philadelphia PA USA
- Department of Pediatrics; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
| | - A. J. Benitez
- Division of Allergy and Immunology; The Children's Hospital of Philadelphia; Philadelphia PA USA
| | - K. Dods
- Division of Gastroenterology, Hepatology, and Nutrition; The Children's Hospital of Philadelphia; Philadelphia PA USA
| | - J. M. Spergel
- Department of Pediatrics; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA USA
- Division of Allergy and Immunology; The Children's Hospital of Philadelphia; Philadelphia PA USA
| | - S. A. Fillon
- University of Colorado School of Medicine; Aurora CO USA
- Digestive Health Institute; Section of Pediatric Gastroenterology, Hepatology and Nutrition; Gastrointestinal Eosinophilic Diseases Program; Mucosal Inflammation Program; Children's Hospital Colorado; Aurora CO USA
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16
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Pelz BJ, Wechsler JB, Amsden K, Johnson K, Singh AM, Wershil BK, Kagalwalla AF, Bryce PJ. IgE-associated food allergy alters the presentation of paediatric eosinophilic esophagitis. Clin Exp Allergy 2016; 46:1431-1440. [PMID: 27388929 DOI: 10.1111/cea.12776] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/23/2016] [Accepted: 06/28/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Links between food allergens and eosinophilic esophagitis (EoE) have been established, but the interplay between EoE- and IgE-associated immediate hypersensitivity to foods remains unclear. OBJECTIVE We sought to determine the prevalence of IgE-associated food allergy at the time of diagnosis of EoE in children and to determine whether differences existed in presentation and disease compared to subjects with EoE alone. METHODS Eosinophilic esophagitis patients were stratified based on the diagnosis of IgE-associated immediate hypersensitivity (EoE + IH vs. EoE-IH). Clinical, histologic, pathologic, and endoscopic differences were investigated using a retrospective database. RESULTS We found that 29% of the 198 EoE patients in our cohort had EoE + IH. These subjects presented at a younger age than those without IH (6.05 vs. 8.09 years, P = 0.013) and were more likely to have comorbid allergic disease. Surprisingly, the EoE + IH group presented with significantly different clinical symptoms, with increased dysphagia, gagging, cough, and poor appetite compared to their counterparts in the EoE-IH group. Male gender, allergic rhinitis, the presence of dysphagia, and younger age were independently associated with having EoE + IH. Specific IgE levels to common EoE-associated foods were higher in EoE + IH, regardless of eliciting immediate hypersensitivity symptoms. In contrast, IgE levels for specific foods triggering EoE were relatively lower in both the groups than IgE levels for immediate reactions. CONCLUSIONS AND CLINICAL RELEVANCE Immediate hypersensitivity is common in children with EoE and identifies a population of EoE patients with distinct clinical characteristics. Our study describes a subtype of EoE in which IgE-mediated food allergy may impact the presentation of paediatric EoE.
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Affiliation(s)
- B J Pelz
- Division of Allergy & Immunology, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Northwestern University Food Allergy Research Consortium, Chicago, IL, USA
| | - J B Wechsler
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - K Amsden
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - A M Singh
- Division of Allergy & Immunology, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Northwestern University Food Allergy Research Consortium, Chicago, IL, USA
| | - B K Wershil
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - A F Kagalwalla
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - P J Bryce
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Northwestern University Food Allergy Research Consortium, Chicago, IL, USA.
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17
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Frischmeyer-Guerrerio PA, Guerrerio AL, Oswald G, Chichester K, Myers L, Halushka MK, Oliva-Hemker M, Wood RA, Dietz HC. TGFβ receptor mutations impose a strong predisposition for human allergic disease. Sci Transl Med 2014; 5:195ra94. [PMID: 23884466 DOI: 10.1126/scitranslmed.3006448] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Transforming growth factor-β (TGFβ) is a multifunctional cytokine that plays diverse roles in physiologic processes as well as human disease, including cancer, heart disease, and fibrotic disorders. In the immune system, TGFβ regulates regulatory T cell (Treg) maturation and immune homeostasis. Although genetic manipulation of the TGFβ pathway modulates immune tolerance in mouse models, the contribution of this pathway to human allergic phenotypes is not well understood. We demonstrate that patients with Loeys-Dietz syndrome (LDS), an autosomal dominant disorder caused by mutations in the genes encoding receptor subunits for TGFβ, TGFBR1 and TGFBR2, are strongly predisposed to develop allergic disease, including asthma, food allergy, eczema, allergic rhinitis, and eosinophilic gastrointestinal disease. LDS patients exhibited elevated immunoglobulin E levels, eosinophil counts, and T helper 2 (TH2) cytokines in their plasma. They had an increased frequency of CD4(+) T cells that expressed both Foxp3 and interleukin-13, but retained the ability to suppress effector T cell proliferation. TH2 cytokine-producing cells accumulated in cultures of naïve CD4(+) T cells from LDS subjects, but not controls, after stimulation with TGFβ, suggesting that LDS mutations support TH2 skewing in naïve lymphocytes in a cell-autonomous manner. The monogenic nature of LDS demonstrates that altered TGFβ signaling can predispose to allergic phenotypes in humans and underscores a prominent role for TGFβ in directing immune responses to antigens present in the environment and foods. This paradigm may be relevant to nonsyndromic presentations of allergic disease and highlights the potential therapeutic benefit of strategies that inhibit TGFβ signaling.
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18
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Ishimura N, Furuta K, Sato S, Ishihara S, Kinoshita Y. Limited role of allergy testing in patients with eosinophilic gastrointestinal disorders. J Gastroenterol Hepatol 2013; 28:1306-13. [PMID: 23489221 DOI: 10.1111/jgh.12197] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM Allergies have been implicated in the pathogenesis of eosinophilic gastrointestinal disorders, although it remains unknown what type of allergen is closely associated with their development. The aim of this study is to investigate the possible involvement of food and/or aeroallergen factors in eosinophilic gastrointestinal disorders. METHODS Eighteen patients with eosinophilic esophagitis (EoE), 23 with eosinophilic gastroenteritis (EGE), and 28 healthy volunteers were enrolled. The levels of total serum immunoglobulin E (IgE) and 33 different allergen-specific IgE antibodies, including those for six foods used in a standard EoE elimination diet, were determined in each subject. Serum antigen-specific IgE levels were measured using a chemiluminescence enzyme immunoassay with a multiple antigen simultaneous test 33 (MAST33). The expression patterns of specific antigens were compared among the groups. RESULTS The mean level of total IgE antibodies was significantly higher in patients with EGE (553.6 ± 115.3 IU/mL) than the healthy volunteers (230.6 ± 87.1 IU/mL). Two thirds of all subjects had sensitivity to at least one inhaled antigen. In positive cases, allergies against multiple antigens were more frequently seen in the EoE and EGE patients. Japanese cedar and dust mite aeroallergens were more prevalent than food antigens. CONCLUSIONS Consistent with higher levels of serum total IgE antibodies, patients with EoE and EGE were frequently sensitized to several different allergens. Reactions to aeroallergens were more prevalent in these groups, although no particular antigen causing EoE and/or EGE was detected by measuring serum antigen-specific IgE antibodies.
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Affiliation(s)
- Norihisa Ishimura
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan.
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19
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Noti M, Tait Wojno ED, Kim BS, Siracusa MC, Giacomin PR, Nair MG, Benitez AJ, Ruymann KR, Muir AB, Hill DA, Chikwava KR, Moghaddam AE, Sattentau QJ, Alex A, Zhou C, Yearley JH, Menard-Katcher P, Kubo M, Obata-Ninomiya K, Karasuyama H, Comeau MR, Brown-Whitehorn T, de Waal Malefyt R, Sleiman PM, Hakonarson H, Cianferoni A, Falk GW, Wang ML, Spergel JM, Artis D. Thymic stromal lymphopoietin-elicited basophil responses promote eosinophilic esophagitis. Nat Med 2013; 19:1005-13. [PMID: 23872715 PMCID: PMC3951204 DOI: 10.1038/nm.3281] [Citation(s) in RCA: 304] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 06/18/2013] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis (EoE) is a food allergy-associated inflammatory disease characterized by esophageal eosinophilia. Current management strategies for EoE are nonspecific, and thus there is a need to identify specific immunological pathways that could be targeted to treat this disease. EoE is associated with polymorphisms in the gene that encodes thymic stromal lymphopoietin (TSLP), a cytokine that promotes allergic inflammation, but how TSLP might contribute to EoE disease pathogenesis has been unclear. Here, we describe a new mouse model of EoE-like disease that developed independently of IgE, but was dependent on TSLP and basophils, as targeting TSLP or basophils during the sensitization phase limited disease. Notably, therapeutic TSLP neutralization or basophil depletion also ameliorated established EoE-like disease. In human subjects with EoE, we observed elevated TSLP expression and exaggerated basophil responses in esophageal biopsies, and a gain-of-function TSLP polymorphism was associated with increased basophil responses in patients with EoE. Together, these data suggest that the TSLP-basophil axis contributes to the pathogenesis of EoE and could be therapeutically targeted to treat this disease.
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Affiliation(s)
- Mario Noti
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elia D. Tait Wojno
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian S. Kim
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark C. Siracusa
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul R. Giacomin
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Centre for Biodiscovery and Molecular Development of Therapeutics, Queensland Tropical Health Alliance, James Cook University, Cairns, Queensland, Australia
| | - Meera G. Nair
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Biomedical Sciences, School of Medicine, University of California-Riverside, Riverside, California, USA
| | - Alain J. Benitez
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kathryn R. Ruymann
- Department of Pediatrics, Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Amanda B. Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David A. Hill
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kudakwashe R. Chikwava
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Amin E. Moghaddam
- The Sir William Dunn School of Pathology, The University of Oxford, Oxford, UK
| | | | - Aneesh Alex
- Department of Electrical and Computer Engineering, Lehigh University, Bethlehem, Pennsylvania, USA
- Center for Photonics and Nanoelectronics, Lehigh University, Bethlehem, Pennsylvania, USA
- Bioengineering Program, Lehigh University, Bethlehem, Pennsylvania, USA
| | - Chao Zhou
- Department of Electrical and Computer Engineering, Lehigh University, Bethlehem, Pennsylvania, USA
- Center for Photonics and Nanoelectronics, Lehigh University, Bethlehem, Pennsylvania, USA
- Bioengineering Program, Lehigh University, Bethlehem, Pennsylvania, USA
| | - Jennifer H. Yearley
- Department of Pathology, Merck Research Laboratories, Palo Alto, California, USA
| | - Paul Menard-Katcher
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Masato Kubo
- Laboratory for Cytokine Regulation, Research Center for Integrative Medical Science, RIKEN Yokohama Institute, Kanagawa, Japan
- Division of Molecular Pathology, Research Institute for Biomedical Science, Tokyo University of Science, Chiba, Japan
| | - Kazushige Obata-Ninomiya
- Department of Immune Regulation, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
- JST, CREST, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hajime Karasuyama
- Department of Immune Regulation, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
- JST, CREST, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | | | - Terri Brown-Whitehorn
- Department of Pediatrics, Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rene de Waal Malefyt
- Therapeutic Area Biology and Pharmacology, Merck Research Laboratories, Palo Alto, California, USA
| | - Patrick M. Sleiman
- Center for Applied Genomics, Abramson Research Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Human Genetics, Abramson Research Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hakon Hakonarson
- Center for Applied Genomics, Abramson Research Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Human Genetics, Abramson Research Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Antonella Cianferoni
- Department of Pediatrics, Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Joint Penn-Children’s Hospital of Philadelphia Center for Digestive, Liver and Pancreatic Medicine, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Molecular Studies in Digestive and Liver Diseases, Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gary W. Falk
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Joint Penn-Children’s Hospital of Philadelphia Center for Digestive, Liver and Pancreatic Medicine, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Molecular Studies in Digestive and Liver Diseases, Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mei-Lun Wang
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Joint Penn-Children’s Hospital of Philadelphia Center for Digestive, Liver and Pancreatic Medicine, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Molecular Studies in Digestive and Liver Diseases, Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan M. Spergel
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Joint Penn-Children’s Hospital of Philadelphia Center for Digestive, Liver and Pancreatic Medicine, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Molecular Studies in Digestive and Liver Diseases, Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Artis
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Joint Penn-Children’s Hospital of Philadelphia Center for Digestive, Liver and Pancreatic Medicine, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Molecular Studies in Digestive and Liver Diseases, Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennyslvania, USA
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Zafra MP, Cancelliere N, Rodríguez del Río P, Ruiz-García M, Estévez L, Andregnette V, Sánchez-García S, Fiandor A, Collantes E, Sastre J, Quirce S, Ibáñez MD, del Pozo V. Misregulation of suppressors of cytokine signaling in eosinophilic esophagitis. J Gastroenterol 2013; 48:910-20. [PMID: 23229770 DOI: 10.1007/s00535-012-0723-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 11/11/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several findings suggest that eosinophilic esophagitis (EoE) is strongly associated with atopy and allergen-driven, Th2-type immune responses, indicating the association of EoE with immune dysregulation. The objective of this study is to ascertain the molecular mechanism involved in EoE disease development a Th2 condition. METHODS 25 patients with diagnosis of EoE and 17 non-EoE controls were recruited by the gastroenterology and allergy departments from three different hospitals. Transcription analysis of suppressors of cytokine signaling 1, 3, 5 (SOCS), interleukin-5 (IL), IL-13, eotaxin (CCL26), eoataxin receptor (CCR3), and mitogen-activated protein kinase 1 (MAPK1) was performed in esophageal biopsies by real time PCR. Western blot of ERK esophageal protein and additional measures of IL-5 and VEGF levels in serum were performed. RESULTS The esophagus of EoE patients expresses and synthesizes high levels of SOCS1 and SOCS3 proteins (P < 0.05), and these expression correlated with levels of IL-5, IL-13, CCL26, CCR3, and MAPK1 genes. In addition, we demonstrate the implication of the ERK pathway (P < 0.001). CONCLUSIONS SOCS proteins probably contribute to EoE pathogenesis by directly or indirectly inducing the Th2 profile, as well as by promoting the production of Th2 cytokines. All these findings further enhance our understanding of the mechanism of EoE, and accumulating evidence suggests that EoE pathogenesis is likely to be due to misregulation of immunological pathways.
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Affiliation(s)
- Ma Paz Zafra
- Department of Immunology, Fundación Jiménez Díaz-Capio, Av. Reyes Católicos 2, 28040, Madrid, Spain
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Tomomatsu Y, Yoshino J, Inui K, Wakabayashi T, Kobayashi T, Miyoshi H, Kosaka T, Yamamoto S, Torii Y. Clinical features of eosinophilic esophagitis: ten Japanese cases. Dig Endosc 2013; 25:117-24. [PMID: 23367878 DOI: 10.1111/j.1443-1661.2012.01340.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM We studied eosinophilic esophagitis (EE) to clarify the clinical and endoscopic features of a Japanese case series. METHODS Records of 10 patients diagnosed with EE at our hospital between May 2010 and December 2011 were examined for age, sex, symptoms, allergic disorder, endoscopic findings, and treatment received. Esophageal wall thickness was measured by endoscopic ultrasonography (EUS). RESULTS Patients were seven males and three females with a mean age of 48 years. Symptoms included dysphagia, heartburn, food impaction, and chest pain. Nine patients had a history of allergic diseases. Increased peripheral eosinophil count was observed in one patient whereas increased immunoglobulin E level was observed in eight patients. Endoscopic findings included longitudinal furrows in all patients, mucosal edema in nine patients, loss of vascular pattern in nine patients, white exudates in six patients, cobblestone-like appearance in five patients, and concentric rings in three patients. EUS revealed thickening of the esophageal wall in one patient. Histopathological examination revealed eosinophilic infiltration (≥15 eosinophils/high-powered field) in the esophageal epithelium of all patients. Treatment was required in six patients. Proton pump inhibitor (PPI) therapy was given as the first-line treatment but was ineffective in four patients and effective in two patients. Steroid therapy was given to three patients unresponsive to PPI therapy and was effective. CONCLUSIONS EE was common among relatively young men and was associated with allergic diseases. Longitudinal furrows were observed as the most characteristic endoscopic finding. Esophageal wall thickening was not commonly observed by EUS.
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Affiliation(s)
- Yuichiro Tomomatsu
- Department of Internal Medicine, Banbuntane Hotokukai Hospital, Fujita Health University, School of Medicine, Nagoya, Japan.
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Menard-Katcher P, Marks KL, Liacouras CA, Spergel JM, Yang YX, Falk GW. The natural history of eosinophilic oesophagitis in the transition from childhood to adulthood. Aliment Pharmacol Ther 2013; 37:114-21. [PMID: 23121227 DOI: 10.1111/apt.12119] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 07/27/2012] [Accepted: 10/10/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is a chronic inflammatory condition affecting both children and adults. Little is known about the natural history of EoE in the transition from childhood into adulthood. AIM To determine the prevalence of EoE symptoms and impact of EoE on quality of life among adults diagnosed with EoE during childhood. METHODS This is a cross-sectional study of EoE patients from the Children's Hospital of Philadelphia EoE registry. Patients ≥18 years diagnosed with EoE during childhood were administered validated dysphagia [Mayo Dysphagia Questionnaire (MDQ)-30] and Quality of Life (PAGI-QOL) questionnaires. Ongoing EoE treatments were ascertained. RESULTS A total of 140 EoE patients ≥18 years were identified; 53 completed all questions. Only 6 (11%) subjects had positive (n = 2) or indeterminate (n = 4) dysphagia scores. However, of 47 patients with negative scores, 18 (37%) reported ongoing difficulty swallowing. The mean PAGI-QOL score was 4.58/5. The dietary dimension score was 3.73/5. Current pharmacological EoE treatments were topical steroids (3/53) and interleukin-5 antagonists (3/53). Additionally, 26/53 (49%) were on PPI therapy and 40/53 (76%) were following allergy directed diets. CONCLUSIONS The majority of young adults diagnosed with EoE during childhood continue to require pharmacological treatment and/or dietary modification for EoE. A substantial proportion of this population experiences ongoing swallowing difficulties that a standard dysphagia questionnaire fails to capture. Dietary quality of life, but not total quality of life, appears to be adversely affected. These data suggest that EoE diagnosed during childhood remains a significant medical issue during early adulthood, and that better EoE symptom measurement instruments are needed.
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Affiliation(s)
- P Menard-Katcher
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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Ali MA, Lam-Himlin D, Voltaggio L. Eosinophilic esophagitis: a clinical, endoscopic, and histopathologic review. Gastrointest Endosc 2012; 76:1224-37. [PMID: 23025974 DOI: 10.1016/j.gie.2012.08.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2012] [Accepted: 08/21/2012] [Indexed: 02/08/2023]
Affiliation(s)
- Mohammed Aamir Ali
- Department of Gastroenterology, George Washington University Hospital, Washington, DC 20037, USA
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Arora AA, Weiler CR, Katzka DA. Eosinophilic esophagitis: allergic contribution, testing, and management. Curr Gastroenterol Rep 2012; 14:206-15. [PMID: 22422505 DOI: 10.1007/s11894-012-0254-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Both basic science and clinical data indicate a strong role for allergy as a cause of eosinophilic esophagitis. As a result, one of the desired goals of therapy is identification and elimination of food antigens that trigger the allergic inflammatory pathway. Traditional methods for identification of causative food antigens include induction of symptoms with exposure to the antigen, demonstration of serum IgE antibodies against antigens and induction of immediate (IgE) or delayed (Th2) reactions against dermal instillation of antigens. Although some data support the use of these tests in patients with eosinophilic esophagitis, they are limited in this disease. This limitation results from an inability to provoke recognizable symptoms and a lack of concordance between allergies identified in the skin and the blood with the antigens that trigger esophageal disease. As a result, allergy therapy in eosinophilic esophagitis consists of global elimination of food antigens with an elemental diet or exclusion of the most common antigens. As compliance is difficult with these strategies, the mainstay of allergy therapy in eosinophilic esophagitis has become the use of medications that blunt the allergic pathway such as steroids with a future aimed toward more specific inhibitors of this pathway in eosinophilic esophagitis specifically.
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Affiliation(s)
- Amindra A Arora
- Department of Gastroenterology and Hepatology, Mayo Foundation, Rochester, MN 55905, USA.
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Spergel JM, Brown-Whitehorn TF, Cianferoni A, Shuker M, Wang ML, Verma R, Liacouras CA. Identification of causative foods in children with eosinophilic esophagitis treated with an elimination diet. J Allergy Clin Immunol 2012; 130:461-7.e5. [DOI: 10.1016/j.jaci.2012.05.021] [Citation(s) in RCA: 296] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 05/21/2012] [Accepted: 05/22/2012] [Indexed: 02/06/2023]
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Paddack A, Gibbons T, Smith C, Patil S, Richter GT. Food hypersensitivity and otolaryngologic conditions in young children. Otolaryngol Head Neck Surg 2012; 147:215-20. [PMID: 22447892 DOI: 10.1177/0194599812441573] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES/HYPOTHESIS To explore the relationship between food hypersensitivity and common upper aerodigestive disorders found in children younger than 2 years. STUDY DESIGN Case control study. SETTING Tertiary pediatric gastroenterology/otolaryngology clinics. METHODS Two-year retrospective chart review of a common cohort of children younger than 2 years with suspected cow's milk protein allergy (CMPA). Patients were managed in both a tertiary pediatric gastroenterology and otolaryngology clinic and compared with a control study group. RESULTS One hundred ninety-one children with CMPA were reviewed. One hundred forty-one had aerodigestive complaints, with 101 having sufficient follow-up to participate in the study. Ninety-one percent of this final patient group demonstrated improved symptoms following dairy elimination. Twenty-five patients (27%) had associated otolaryngologic (ear, nose, and throat [ENT]) issues that had been refractory to maximal gastroesophageal reflux therapy. The most common associated upper aerodigestive conditions were persistent upper airway congestion (72%) and oropharyngeal dysphagia (80%). Sixty percent of ENT disease improved with elimination diet. Eosinophilic esophagitis was noted in 36% of the cohort who had mucosal biopsies performed. Otolaryngology intervention was much more common in the cohort of children with CMPA compared with controls (odds ratio, 33.78; 95% confidence interval, 7.55, 151.03). CONCLUSIONS CMPA is difficult to diagnose because of limited accurate diagnostic tools, especially in young children. This study suggests a relationship between CMPA and otolaryngologic conditions in children younger than 2 years. Some patients in this study showed symptom improvement via an elimination diet. Early recognition of otolaryngologic manifestations of CMPA may help manage this condition in young children.
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Affiliation(s)
- Angela Paddack
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas 72205, USA.
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Spergel JM, Rothenberg ME, Collins MH, Furuta GT, Markowitz JE, Fuchs G, O'Gorman MA, Abonia JP, Young J, Henkel T, Wilkins HJ, Liacouras CA. Reslizumab in children and adolescents with eosinophilic esophagitis: results of a double-blind, randomized, placebo-controlled trial. J Allergy Clin Immunol 2011; 129:456-63, 463.e1-3. [PMID: 22206777 DOI: 10.1016/j.jaci.2011.11.044] [Citation(s) in RCA: 375] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 11/03/2011] [Accepted: 11/22/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Eosinophilic esophagitis is a chronic allergic disease with insufficient treatment options. Results from animal studies suggest that IL-5 induces eosinophil trafficking in the esophagus. OBJECTIVE We sought to evaluate the effect of reslizumab, a neutralizing antibody against IL-5, in children and adolescents with eosinophilic esophagitis. METHODS Patients with symptom severity scores of moderate or worse and an esophageal biopsy specimen with 24 or more intraepithelial eosinophils per high-power field were randomly assigned to receive infusions of 1, 2, or 3 mg/kg reslizumab or placebo at weeks 0, 4, 8, and 12. The coprimary efficacy measures were changes in peak esophageal eosinophil count and the physician's global assessment score at week 15 (end of therapy). RESULTS Two-hundred twenty-six patients received study medication. Median reductions from baseline to the end of therapy in peak esophageal eosinophil counts were 59%, 67%, 64%, and 24% in the 1, 2, and 3 mg/kg reslizumab (all P < .001) and placebo groups, respectively. All treatment groups, including the placebo group, showed improvements in physician's global assessment scores; the differences between the reslizumab and placebo groups were not statistically significant. The most common adverse events in the reslizumab groups were headache, cough, nasal congestion, and upper respiratory tract infection. One patient in each reslizumab group and 2 in the placebo group had serious adverse events; none were considered related to the study medication. CONCLUSION Reslizumab significantly reduced intraepithelial esophageal eosinophil counts in children and adolescents with eosinophilic esophagitis. However, improvements in symptoms were observed in all treatment groups and were not associated with changes in esophageal eosinophil counts.
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Affiliation(s)
- Jonathan M Spergel
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Genetic dissection of eosinophilic esophagitis provides insight into disease pathogenesis and treatment strategies. J Allergy Clin Immunol 2011; 128:23-32; quiz 33-4. [PMID: 21570716 DOI: 10.1016/j.jaci.2011.03.046] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 03/29/2011] [Accepted: 03/30/2011] [Indexed: 01/01/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder of the esophagus that is compounded by both genetic predisposition and aberrant responses to environmental antigens, particularly those that are food derived. Data have indicated a unique transcriptional response in vivo that defines EoE and that appears to be partially attributable to the T(H)2 cytokine IL-13. Moreover, a number of genetic risk variants in proinflammatory and epithelial cell genes associate with EoE susceptibility, demonstrating novel heritable mechanisms that contribute to disease risk. Here we discuss recent advances in our understanding of the intrinsic (genetic) and extrinsic (environmental) components that illustrate the complex nature of EoE.
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Abreu-Velez AM, Howard MS, Smoller BR. Atopic dermatitis with possible polysensitization and monkey esophagus reactivity. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2010; 2:336-40. [PMID: 22558585 PMCID: PMC3341643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
CONTEXT Atopic dermatitis is a chronic inflammatory skin disease resulting from interactions between environmental and genetic factors. Recent studies link atopic dermatitis with asthma and with eosinophilic esophagitis. CASE REPORT Based on this association, we investigated by indirect immunofluorescence the immunoreactivity patterns on monkey esophagus substrate utilizing the serum of a patient with severe atopic dermatitis. We also examined the patient's skin biopsy by H&E histology and immunohistochemistry. We detected strong deposits of albumin, IgE, IgG, IgD, IgA, Complement/C1q and mast cell tryptase in multiples structures of the skin, as well as a broad pattern of intraepithelial staining on monkey esophagus. Strong staining positivity was also detected within the inflammatory infiltrate around the upper dermal vessels, as well as additional positive staining for the human leukocyte antigen system antigens DR DP and DQ. CONCLUSION Our findings demonstrate that there could be an indication for testing patients with severe atopic dermatitis for autoreactivity to filaggrin (anti-keratin antibodies) utilizing monkey esophagus. Larger studies are needed to clarify any immunologic interaction between the reactivity to albumin and food allergens that may sensitize patients via the esophageal mucosa.
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Affiliation(s)
- Ana Maria Abreu-Velez
- Georgia Dermatopathology Associates, Atlanta, Georgia, USA.,Correspondence to: Ana Maria Abreu-Velez, Georgia Dermatopathology Associates, 1534 North Decatur Rd. NE, Suite 206, Atlanta, GA 30307-1000, USA. Tel.: (404) 371 0027, Fax: (404) 876 4897,
| | | | - Bruce R. Smoller
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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