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Yadavalli CS, Upparahalli Venkateshaiah S, Verma AK, Kathera C, Duncan PS, Vaezi M, Paul RJ, Mishra A. Vasoactive Intestinal Peptide Receptor, CRTH2, Antagonist Treatment Improves Eosinophil and Mast Cell-Mediated Esophageal Remodeling and Motility Dysfunction in Eosinophilic Esophagitis. Cells 2024; 13:295. [PMID: 38391908 PMCID: PMC10886969 DOI: 10.3390/cells13040295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND AND AIMS Ultrasonography has shown that eosinophils accumulate in each segment of the esophageal mucosa in human EoE, ultimately promoting esophageal motility dysfunction; however, no mechanistic evidence explains how or why this accumulation occurs. METHODS Quantitative PCR, ELISA, flow cytometry, immunostaining, and immunofluorescence analyses were performed using antibodies specific to the related antigens and receptors. RESULTS In deep esophageal biopsies of EoE patients, eosinophils and mast cells accumulate adjacent to nerve cell-derived VIP in each esophageal segment. qRT-PCR analysis revealed five- to sixfold increases in expression levels of VIP, CRTH2, and VAPC2 receptors and proteins in human blood- and tissue-accumulated eosinophils and mast cells. We also observed a significant correlation between mRNA CRTH2 levels and eosinophil- and nerve cell-derived VIPs in human EoE (p < 0.05). We provide evidence that eosinophil and mast cell deficiency following CRTH2 antagonist treatment improves motility dysfunction in a chronic DOX-inducible CC10-IL-13 murine model of experimental EoE. CONCLUSIONS CRTH2 antagonist treatment is a novel therapeutic strategy for inflammatory cell-induced esophageal motility dysfunction in IL-13-induced chronic experimental EoE.
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Affiliation(s)
- Chandra Sekhar Yadavalli
- Department of Medicine, Section of Pulmonary Diseases, Tulane Eosinophilic Disorder Center, School of Medicine, Tulane University, New Orleans, LA 70112, USA; (C.S.Y.); (S.U.V.); (C.K.)
| | - Sathisha Upparahalli Venkateshaiah
- Department of Medicine, Section of Pulmonary Diseases, Tulane Eosinophilic Disorder Center, School of Medicine, Tulane University, New Orleans, LA 70112, USA; (C.S.Y.); (S.U.V.); (C.K.)
| | - Alok K. Verma
- Division of Gastroenterology, Cincinnati Childrens Medical Center, Cincinnati, OH 45229, USA;
| | - Chandrasekhar Kathera
- Department of Medicine, Section of Pulmonary Diseases, Tulane Eosinophilic Disorder Center, School of Medicine, Tulane University, New Orleans, LA 70112, USA; (C.S.Y.); (S.U.V.); (C.K.)
| | - Pearce S. Duncan
- Division of Gastroenterology, School of Medicine, Tulane University, New Orleans, LA 70118, USA;
| | - Michael Vaezi
- Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Richard J. Paul
- Division of Physiology, Cincinnati University, Cincinnati, OH 45220, USA;
| | - Anil Mishra
- Department of Medicine, Section of Pulmonary Diseases, Tulane Eosinophilic Disorder Center, School of Medicine, Tulane University, New Orleans, LA 70112, USA; (C.S.Y.); (S.U.V.); (C.K.)
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2
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Marella S, Sharma A, Ganesan V, Ferrer-Torres D, Krempski JW, Idelman G, Clark S, Nasiri Z, Vanoni S, Zeng C, Dlugosz AA, Zhou H, Wang S, Doyle AD, Wright BL, Spence JR, Chehade M, Hogan SP. IL-13-induced STAT3-dependent signaling networks regulate esophageal epithelial proliferation in eosinophilic esophagitis. J Allergy Clin Immunol 2023; 152:1550-1568. [PMID: 37652141 PMCID: PMC11102758 DOI: 10.1016/j.jaci.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 07/11/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Basal zone hyperplasia (BZH) and dilated intercellular spaces (DISs) are thought to contribute to the clinical manifestations of eosinophilic esophagitis (EoE); however, the molecular pathways that drive BZH remain largely unexplored. OBJECTIVE We sought to define the role of IL-13-induced transcriptional programs in esophageal epithelial proliferation in EoE. METHODS We performed RNA sequencing, bioinformatics, Western blot, reverse transcriptase quantitative PCR, and histologic analyses on esophageal biopsies from healthy control and patients with EoE, primary esophageal cells derived from patients with EoE, and IL-13-stimulated esophageal epithelial keratinocytes grown at the air-liquid interface (EPC2-ALI). Genetic (shRNA) and pharmacologic (proteolysis-targeting chimera degrader) approaches and in vivo model of IL-13-induced esophageal epithelial remodeling (Krt5-rtTA x tetO-IL-13Tg) were used to define the role of signal transducer and activator of transcription 3 (STAT3) and STAT6 and secreted frizzled-related protein 1 (SFRP1) in esophageal epithelial proliferation. RESULTS RNA-sequencing analysis of esophageal biopsies (healthy control vs EoE) and EPC2-ALI revealed 82 common differentially expressed genes that were enriched for putative STAT3 target genes. In vitro and in vivo analyses revealed a link between IL-13-induced STAT3 and STAT6 phosphorylation, SFRP1 mRNA expression, and esophageal epithelial proliferation. In vitro studies showed that IL-13-induced esophageal epithelial proliferation was STAT3-dependent and regulated by the STAT3 target SFRP1. SFRP1 mRNA is increased in esophageal biopsies from patients with active EoE compared with healthy controls or patients in remission and identifies an esophageal suprabasal epithelial cell subpopulation that uniquely expressed the core EoE proinflammatory transcriptome genes (CCL26, ALOX15, CAPN14, ANO1, and TNFAIP6). CONCLUSIONS These studies identify SFRP1 as a key regulator of IL-13-induced and STAT3-dependent esophageal proliferation and BZH in EoE and link SFRP1+ esophageal epithelial cells with the proinflammatory and epithelial remodeling response in EoE.
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Affiliation(s)
- Sahiti Marella
- Department of Pathology, University of Michigan, Ann Arbor, Mich
| | - Ankit Sharma
- Department of Pathology, University of Michigan, Ann Arbor, Mich; Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, Mich
| | - Varsha Ganesan
- Department of Pathology, University of Michigan, Ann Arbor, Mich; Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, Mich
| | | | - James W Krempski
- Department of Pathology, University of Michigan, Ann Arbor, Mich; Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, Mich
| | - Gila Idelman
- Department of Pathology, University of Michigan, Ann Arbor, Mich; Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, Mich
| | - Sydney Clark
- Department of Pathology, University of Michigan, Ann Arbor, Mich
| | - Zena Nasiri
- College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, Mich
| | - Simone Vanoni
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chang Zeng
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrej A Dlugosz
- Department of Dermatology, University of Michigan, Ann Arbor, Mich
| | - Haibin Zhou
- Pharmacology and Medicinal Chemistry, University of Michigan, Ann Arbor, Mich
| | - Shaomeng Wang
- Pharmacology and Medicinal Chemistry, University of Michigan, Ann Arbor, Mich
| | - Alfred D Doyle
- Division of Allergy, Asthma and Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Ariz
| | - Benjamin L Wright
- Division of Allergy, Asthma and Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Ariz; Section of Allergy and Immunology, Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Jason R Spence
- Internal Medicine, University of Michigan, Ann Arbor, Mich
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Simon P Hogan
- Department of Pathology, University of Michigan, Ann Arbor, Mich; Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, Mich.
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3
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Massironi S, Mulinacci G, Gallo C, Elvevi A, Danese S, Invernizzi P, Vespa E. Mechanistic Insights into Eosinophilic Esophagitis: Therapies Targeting Pathophysiological Mechanisms. Cells 2023; 12:2473. [PMID: 37887317 PMCID: PMC10605530 DOI: 10.3390/cells12202473] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease characterized by eosinophilic infiltration of the esophagus. It arises from a complex interplay of genetic predisposition (susceptibility loci), environmental triggers (allergens and dietary antigens), and a dysregulated immune response, mainly mediated by type 2 T helper cell (Th2)-released cytokines, such as interleukin (IL)-4, IL-5, and IL-13. These cytokines control eosinophil recruitment and activation as well as tissue remodeling, contributing to the characteristic features of EoE. The pathogenesis of EoE includes epithelial barrier dysfunction, mast cell activation, eosinophil degranulation, and fibrosis. Epithelial barrier dysfunction allows allergen penetration and promotes immune cell infiltration, thereby perpetuating the inflammatory response. Mast cells release proinflammatory mediators and promote eosinophil recruitment and the release of cytotoxic proteins and cytokines, causing tissue damage and remodeling. Prolonged inflammation can lead to fibrosis, resulting in long-term complications such as strictures and dysmotility. Current treatment options for EoE are limited and mainly focus on dietary changes, proton-pump inhibitors, and topical corticosteroids. Novel therapies targeting key inflammatory pathways, such as monoclonal antibodies against IL-4, IL-5, and IL-13, are emerging in clinical trials. A deeper understanding of the complex pathogenetic mechanisms behind EoE will contribute to the development of more effective and personalized therapeutic strategies.
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Affiliation(s)
- Sara Massironi
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (G.M.); (C.G.); (A.E.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Giacomo Mulinacci
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (G.M.); (C.G.); (A.E.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Camilla Gallo
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (G.M.); (C.G.); (A.E.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Alessandra Elvevi
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (G.M.); (C.G.); (A.E.)
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (G.M.); (C.G.); (A.E.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Edoardo Vespa
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy
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Ptaschinski C, Zhu D, Fonseca W, Lukacs NW. Stem cell factor inhibition reduces Th2 inflammation and cellular infiltration in a mouse model of eosinophilic esophagitis. Mucosal Immunol 2023; 16:727-739. [PMID: 37557983 PMCID: PMC10680063 DOI: 10.1016/j.mucimm.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023]
Abstract
Eosinophilic esophagitis (EoE) is a T helper (Th)2-mediated inflammatory disorder characterized endoscopically by eosinophilic infiltration leading to fibrosis of the esophagus. Stem cell factor (SCF), a multifunctional cytokine, is upregulated in several allergic diseases, including in patients with EoE. Mast cells and eosinophils express c-kit, the cell surface receptor for SCF, and have been found to play an important role in EoE. Therefore, we investigated whether blocking SCF represents a potential therapeutic approach for EoE. Esophageal inflammation was induced in mice using peanut allergen. In mice with experimental EoE, we found that SCF was upregulated in the esophageal tissue. In EoE mice injected with a polyclonal antibody specific for SCF, we observed a decrease in both mast cells and eosinophils by histological and flow cytometric analysis. Furthermore, Th2 cytokines in the esophagus were decreased in anti-SCF treated mice, as were levels of Th2 cytokines from lung-draining and esophageal lymph nodes. Serum levels of peanut-specific immunoglobulin E were reduced following treatment with anti-SCF. In Kitlf/f-Col1-Cre-ERT mice, which have SCF deleted primarily in myofibroblasts that develop in EoE, we observed similar results as the anti-SCF treated animals for inflammatory cell accumulation, cytokines, and histopathology. These results indicate that therapeutic treatments targeting SCF can reduce allergic inflammation in EoE.
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Affiliation(s)
- Catherine Ptaschinski
- Department of Pathology, University of Michigan, Ann Arbor, USA; Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, USA.
| | - Diana Zhu
- Department of Pathology, University of Michigan, Ann Arbor, USA
| | - Wendy Fonseca
- Department of Pathology, University of Michigan, Ann Arbor, USA
| | - Nicholas W Lukacs
- Department of Pathology, University of Michigan, Ann Arbor, USA; Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, USA
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5
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Janarthanam R, Kuang FL, Zalewski A, Amsden K, Wang MY, Ostilla L, Keeley K, Hirano I, Kagalwalla A, Wershil BK, Gonsalves N, Wechsler JB. Bulk T-cell receptor sequencing confirms clonality in pediatric eosinophilic esophagitis and identifies a food-specific repertoire. Allergy 2023; 78:2487-2496. [PMID: 37203302 PMCID: PMC10768854 DOI: 10.1111/all.15773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 03/15/2023] [Accepted: 04/04/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) involves a chronic immune-mediated response to dietary antigens. Recent work identifies T-cell clonality in children with EoE, however, it is unknown whether this is true in adults or whether there is a restricted food-specific T-cell repertoire. We sought to confirm T-cell receptor (TCR) clonality in EoE and assess for differences with specific food triggers. METHODS Bulk TCR sequencing was performed on mRNA isolated from esophageal biopsies obtained from adults and children with EoE (n = 15) who had food triggers confirmed by endoscopic evaluation. Non-EoE adult and pediatric controls (n = 10) were included. Differences in TCR clonality by disease and treatment status were assessed. Shared and similar V-J-CDR3s were assessed based on specific food triggers. RESULTS Active EoE biopsies from children but not adults displayed decreased unique TCRα/β clonotypes and increased relative abundance of TCRs comprising >1% of the total compared to non-EoE controls and paired inactive EoE samples. Among patients in which baseline, post diet elimination, and food trigger reintroduction samples (n = 6) were obtained, we observed ~1% of TCRs were shared only between pre-diet elimination and trigger reintroduction. Patients with a shared EoE trigger (milk) had a greater degree of shared and similar TCRs compared to patients with differing triggers (seafood, wheat, egg, soy). CONCLUSION We confirmed relative clonality in children but not adults with active EoE and identified potential food-specific TCRs, particularly for milk-triggered EoE. Further studies are needed to better identify the broad TCR repertoire relevant to food triggers.
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Affiliation(s)
- Rethavathi Janarthanam
- Division of Gastroenterology, Hepatology & Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg school of Medicine, Chicago, Illinois, USA
| | - Fei Li Kuang
- Division of Allergy-Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Angelika Zalewski
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katie Amsden
- Division of Gastroenterology, Hepatology & Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg school of Medicine, Chicago, Illinois, USA
| | - Ming-Yu Wang
- Division of Gastroenterology, Hepatology & Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg school of Medicine, Chicago, Illinois, USA
| | - Lorena Ostilla
- Division of Gastroenterology, Hepatology & Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg school of Medicine, Chicago, Illinois, USA
| | - Kaitlyn Keeley
- Division of Gastroenterology, Hepatology & Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg school of Medicine, Chicago, Illinois, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Amir Kagalwalla
- Department of Pediatrics, John H. Stroger Cook County Hospital of Chicago, Chicago, Illinois, USA
| | - Barry K Wershil
- Division of Gastroenterology, Hepatology & Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg school of Medicine, Chicago, Illinois, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joshua B Wechsler
- Division of Gastroenterology, Hepatology & Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg school of Medicine, Chicago, Illinois, USA
- Division of Allergy-Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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6
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Qin L, Tang LF, Cheng L, Wang HY. The clinical significance of allergen-specific IgG4 in allergic diseases. Front Immunol 2022; 13:1032909. [PMID: 36389804 PMCID: PMC9648126 DOI: 10.3389/fimmu.2022.1032909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/20/2022] [Indexed: 09/10/2023] Open
Abstract
IgG4 is a subclass of IgG antibody with a unique molecular feature of (Fragment antigen- binding) Fab-arm exchange, allowing bispecific antigen binding in a mono-valent manner. With low binding affinity to C1q and Fcγreceptors, IgG4 is incapable of forming immune complexes and activating the complement pathway, exhibiting a non-inflammatory feature. IgG4 is produced similarly to IgE and is considered a modified reaction to IgE class-switching response under certain conditions. It could also counteract IgE-activated inflammation. However, the clinical significance of IgG4 in allergic diseases is complex and controversial. Three viewpoints have been suggested to describe the role of IgG4. IgG4 can act as a tolerance-inducer to play a protective role under repeated and rapid incremental dosing of allergen exposure in allergen immunotherapy (AIT), supported by allergies in cat raisers and venom desensitization in beekeepers. Another viewpoint accepted by mainstream specialists and guidelines of Food Allergy and Management in different countries points out that food-specific IgG4 is a bystander in food allergy and should not be used as a diagnostic tool in clinical work. However, eosinophilic esophagitis (EoE) investigation revealed a direct clinical relevance between physiopathology and serum IgG4 in cow milk and wheat. These factors indicate that allergen-specific IgG4 plays a multifaceted role in allergic diseases that is protective or pathogenic depending on different allergens or exposure conditions.
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Affiliation(s)
- Lu Qin
- Department of Pulmonology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Lan-Fang Tang
- Department of Pulmonology, the Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Lei Cheng
- Department of Otorhinolaryngology & Clinical Allergy Center, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Hui-Ying Wang
- Department of Allergy and Clinical Immunology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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7
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Khokhar D, Marella S, Idelman G, Chang JW, Chehade M, Hogan SP. Eosinophilic esophagitis: Immune mechanisms and therapeutic targets. Clin Exp Allergy 2022; 52:1142-1156. [PMID: 35778876 PMCID: PMC9547832 DOI: 10.1111/cea.14196] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/08/2022] [Accepted: 06/20/2022] [Indexed: 01/26/2023]
Abstract
Eosinophilic esophagitis (EoE) is an emerging chronic inflammatory disease of the oesophagus and is clinically characterized by upper gastrointestinal (GI) symptoms including dysphagia and esophageal food impaction. Histopathologic manifestations, which include intraepithelial eosinophilic inflammation and alterations of the esophageal squamous epithelium, such as basal zone hyperplasia (BZH) and dilated intercellular spaces (DIS), are thought to contribute to esophageal dysfunction and disease symptoms. Corroborative clinical and discovery science-based studies have established that EoE is characterized by an underlying allergic inflammatory response, in part, related to the IL-13/CCL26/eosinophil axis driving dysregulation of several key epithelial barrier and proliferative regulatory genes including kallikrein (KLK) serine proteases, calpain 14 (CAPN14) and anoctamin 1 (ANO1). The contribution of these inflammatory and proliferative processes to the clinical and histological manifestations of disease are not fully elucidated. Herein, we discuss the immune molecules and cells that are thought to underlie the clinical and pathologic manifestations of EoE and the emerging therapeutics targeting these processes for the treatment of EoE.
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Affiliation(s)
- Dilawar Khokhar
- Division of Allergy and ImmunologyUniversity of MichiganAnn ArborMichiganUSA
- Mary H Weiser Food Allergy CenterUniversity of MichiganAnn ArborMichiganUSA
| | - Sahiti Marella
- Mary H Weiser Food Allergy CenterUniversity of MichiganAnn ArborMichiganUSA
- Department of PathologyUniversity of MichiganAnn ArborMichiganUSA
| | - Gila Idelman
- Mary H Weiser Food Allergy CenterUniversity of MichiganAnn ArborMichiganUSA
| | - Joy W. Chang
- Division of Gastroenterology, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic DisordersIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Simon P. Hogan
- Mary H Weiser Food Allergy CenterUniversity of MichiganAnn ArborMichiganUSA
- Department of PathologyUniversity of MichiganAnn ArborMichiganUSA
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8
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Marabotto E, Giannini EG, Zentilin P, Ziola S, Djahandideh Sheijani A, Savarino E, Savarino V. Pharmacotherapies in eosinophilic esophagitis: state of the art. Minerva Gastroenterol (Torino) 2022; 68:69-76. [PMID: 35302339 DOI: 10.23736/s2724-5985.21.02781-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Eosinophilic esophagitis is a chronic immune-mediated esophageal disease with a Th2 inflammatory response to inhalant and food allergens that cause an eosinophilic infiltration of esophageal mucosa. The diagnosis requires an upper endoscopy with esophageal bioptic samples, in particular the number of eosinophils must be >15 eos/high power field. The main symptoms of EoE in adults are dysphagia and food impaction, and its incidence is growing. Nowadays, the etiology of EoE is not well understood and no standard therapy is available. Therefore, the aim of this review was to analyze the major studies present in literature regarding the various therapeutic approaches to this disease.
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Affiliation(s)
- Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy -
| | - Edoardo G Giannini
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Sebastiano Ziola
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | | | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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9
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Racca F, Pellegatta G, Cataldo G, Vespa E, Carlani E, Pelaia C, Paoletti G, Messina MR, Nappi E, Canonica GW, Repici A, Heffler E. Type 2 Inflammation in Eosinophilic Esophagitis: From Pathophysiology to Therapeutic Targets. Front Physiol 2022; 12:815842. [PMID: 35095572 PMCID: PMC8790151 DOI: 10.3389/fphys.2021.815842] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/09/2021] [Indexed: 12/11/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease of the esophagus characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation, whose incidence is rising. It significantly affects patients’ quality of life and, if left untreated, results in fibrotic complications. Although broad consensus has been achieved on first-line therapy, a subset of patients remains non-responder to standard therapy. The pathogenesis of EoE is multifactorial and results from the complex, still mostly undefined, interaction between genetics and intrinsic factors, environment, and antigenic stimuli. A deep understanding of the pathophysiology of this disease is pivotal for the development of new therapies. This review provides a comprehensive description of the pathophysiology of EoE, starting from major pathogenic mechanisms (genetics, type 2 inflammation, epithelial barrier dysfunction, gastroesophageal reflux, allergens, infections and microbiota) and subsequently focusing on the single protagonists of type 2 inflammation (involved cells, cytokines, soluble effectors, surface proteins and transcription factors) that could represent present and future therapeutic targets, while summarizing previous therapeutic approaches in literature.
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Affiliation(s)
- Francesca Racca
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- *Correspondence: Francesca Racca,
| | - Gaia Pellegatta
- Digestive Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Giuseppe Cataldo
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Edoardo Vespa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Digestive Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Elisa Carlani
- Digestive Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Corrado Pelaia
- Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Maria Rita Messina
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Emanuele Nappi
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Digestive Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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10
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Cortes LM, Brodsky D, Chen C, Pridgen T, Odle J, Snider DB, Cruse G, Putikova A, Masuda MY, Doyle AD, Wright BL, Dawson HD, Blikslager A, Dellon ES, Laster SM, Käser T. Immunologic and pathologic characterization of a novel swine biomedical research model for eosinophilic esophagitis. FRONTIERS IN ALLERGY 2022; 3:1029184. [PMID: 36452260 PMCID: PMC9701751 DOI: 10.3389/falgy.2022.1029184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/18/2022] [Indexed: 11/15/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic allergy-mediated condition with an increasing incidence in both children and adults. Despite EoE's strong impact on human health and welfare, there is a large unmet need for treatments with only one recently FDA-approved medication for EoE. The goal of this study was to establish swine as a relevant large animal model for translational biomedical research in EoE with the potential to facilitate development of therapeutics. We recently showed that after intraperitoneal sensitization and oral challenge with the food allergen hen egg white protein (HEWP), swine develop esophageal eosinophilia-a hallmark of human EoE. Herein, we used a similar sensitization and challenge treatment and evaluated immunological and pathological markers associated with human EoE. Our data demonstrate that the incorporated sensitization and challenge treatment induces (i) a systemic T-helper 2 and IgE response, (ii) a local expression of eotaxin-1 and other allergy-related immune markers, (iii) esophageal eosinophilia (>15 eosinophils/0.24 mm2), and (iv) esophageal endoscopic findings including linear furrows and white exudates. Thereby, we demonstrate that our sensitization and oral challenge protocol not only induces the underlying immune markers but also the micro- and macro-pathological hallmarks of human EoE. This swine model for EoE represents a novel relevant large animal model that can drive translational biomedical research to develop urgently needed treatment strategies for EoE.
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Affiliation(s)
- Lizette M Cortes
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.,Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
| | - David Brodsky
- Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.,Department of Biological Sciences, North Carolina State University, Raleigh, NC, United States
| | - Celine Chen
- USDA, ARS, Diet, Genomics and Immunology Laboratory, Beltsville, MD, United States
| | - Tiffany Pridgen
- Department of Clinical Sciences, North Carolina State University, Raleigh, NC, United States
| | - Jack Odle
- Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.,Laboratory of Developmental Nutrition, Department of Animal Science, North Carolina State University, Raleigh, NC, United States
| | - Douglas B Snider
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, United States
| | - Glenn Cruse
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, United States
| | - Arina Putikova
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Mia Y Masuda
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Department of Immunology, Mayo Clinic, Rochester, MN, United States.,Department of Immunology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Alfred D Doyle
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Section of Allergy and Immunology, Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Harry D Dawson
- USDA, ARS, Diet, Genomics and Immunology Laboratory, Beltsville, MD, United States
| | - Anthony Blikslager
- Department of Clinical Sciences, North Carolina State University, Raleigh, NC, United States
| | - Evan S Dellon
- Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.,Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Scott M Laster
- Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.,Department of Biological Sciences, North Carolina State University, Raleigh, NC, United States
| | - Tobias Käser
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.,Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
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11
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Dilollo J, Rodríguez‐López EM, Wilkey L, Martin EK, Spergel JM, Hill DA. Peripheral markers of allergen-specific immune activation predict clinical allergy in eosinophilic esophagitis. Allergy 2021; 76:3470-3478. [PMID: 33840099 DOI: 10.1111/all.14854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/23/2021] [Accepted: 03/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a T-cell-mediated disease that is caused by specific foods and results in esophageal dysfunction. Existing allergy testing modalities are not helpful when attempting to identify EoE-causal foods necessitating empiric food elimination and recurrent endoscopy. The goal of this study was to identify and compare allergen-specific immune features that can be assayed in a minimally invasive manner to predict clinical food allergy in EoE. METHODS We obtained blood samples from control subjects (n = 17), subjects with clinical EoE milk allergy (n = 17), and subjects with immunoglobulin E-mediated milk allergy (n = 9). We measured total and milk-specific plasma immunoglobulin G (IgG)4 levels and peripheral memory CD4+ T helper (TH ) cell proliferation and cytokine production after stimulation with endotoxin-depleted milk proteins. Sensitivity and specificity for predicting clinical EoE milk allergy were calculated and compared between approaches. RESULTS Total and milk-specific IgG4 levels were not significantly different between control subjects and subjects with clinical EoE milk allergy. Stimulation with milk proteins caused TH lymphocytes from subjects with clinical EoE milk allergy to proliferate more (%P1 of 38.3 ± 4.6 vs. 12.7 ± 2.8, p < 0.0001), and produce more type 2 cytokines (%IL-4+ of 33.7 ± 2.8 vs. 6.9 ± 1.6, p < 0.0001) than cells from control subjects. Milk-dependent memory TH -cell proliferation (sensitivity and specificity of 88% and 82%, respectively) and interleukin 4 (IL-4) production (sensitivity and specificity of 100%) most strongly predicted clinical EoE milk allergy. CONCLUSIONS Peripheral markers of allergen-specific immune activation may be useful in identifying EoE-causal foods. Assaying milk-dependent IL-4 production by circulating memory TH lymphocytes most accurately predicts clinical EoE milk allergy.
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Affiliation(s)
- Julianna Dilollo
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
| | - Eric M. Rodríguez‐López
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
- Institute for Immunology and Department of Pediatrics Perelman School of Medicine Philadelphia PA USA
| | - Leah Wilkey
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
| | - Elizabeth K. Martin
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
| | - Jonathan M. Spergel
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
- Institute for Immunology and Department of Pediatrics Perelman School of Medicine Philadelphia PA USA
| | - David A. Hill
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
- Institute for Immunology and Department of Pediatrics Perelman School of Medicine Philadelphia PA USA
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12
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Bidirectional crosstalk between eosinophils and esophageal epithelial cells regulates inflammatory and remodeling processes. Mucosal Immunol 2021; 14:1133-1143. [PMID: 33972688 PMCID: PMC8380647 DOI: 10.1038/s41385-021-00400-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 02/04/2023]
Abstract
Eosinophils accumulate adjacent to epithelial cells in the mucosa of patients with eosinophilic esophagitis (EoE), yet the bidirectional communication between these cells is not well understood. Herein, we investigated the crosstalk between human eosinophils and esophageal epithelial cells. We report that blood-derived eosinophils have prolonged survival when cocultured with epithelial cells; 96 ± 1% and 30 ± 6% viability was observed after 7 and 14 days of coculture, respectively, compared with 1 ± 0% and 0 ± 0% of monoculture. In the presence of IL-13 and epithelial cells, eosinophils had greater survival (68 ± 1%) at 14 days compared with cocultures lacking IL-13. Prolonged eosinophil viability did not require cellular contact and was observed when eosinophils were cultured in conditioned media from esophageal epithelial cells; neutralizing GM-CSF attenuated eosinophil survival. The majority of eosinophil transcripts (58%) were dysregulated in cocultured eosinophils compared with freshly isolated cells. Analysis of epithelial cell transcripts indicated that exposure to eosinophils induced differential expression of a subset of genes that were part of the EoE esophageal transcriptome. Collectively, these results uncover a network of crosstalk between eosinophils and esophageal epithelial cells involving epithelial mediated eosinophil survival and reciprocal changes in cellular transcripts, events likely to occur in EoE.
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13
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Ruffner MA, Zhang Z, Maurer K, Muir AB, Cianferoni A, Sullivan KE, Spergel JM. RNA sequencing identifies global transcriptional changes in peripheral CD4 + cells during active oesophagitis and following epicutaneous immunotherapy in eosinophilic oesophagitis. Clin Transl Immunology 2021; 10:e1314. [PMID: 34322233 PMCID: PMC8296633 DOI: 10.1002/cti2.1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 04/28/2021] [Accepted: 06/25/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE There are no disease-modifying therapies for the treatment of eosinophilic oesophagitis (EoE), which is driven by non-IgE-mediated allergic inflammation. A recent clinical trial of milk epicutaneous immunotherapy (EPIT) has shown initial promise, with 47% of treated EoE patients tolerating milk without recurrence of disease. Mechanisms of EPIT in EoE have not been studied in humans. Here, we identify transcriptional changes in the peripheral CD4+ T-cell compartment during active EoE and following EPIT. METHODS RNA isolation, sequencing and integrative data analysis were performed on peripheral CD4+ T cells isolated from 15 of 20 patients enrolled in a clinical trial of EPIT for EoE. Gene expression changes in peripheral CD4+ T cells were examined during diet therapy and following trial of milk antigen EPIT. RESULTS We identify 244 differentially expressed genes in peripheral blood CD4+ cells of EoE patients consuming versus those eliminating milk, and 129 DEGs in CD4+ cells were isolated after EPIT versus after placebo (FDR ≤ 0.05). Gene set enrichment analysis identifies enrichment of hallmark interferon-α and interferon-γ response pathways in peripheral CD4+ T cells from EoE patients during active disease on a milk-containing diet. We demonstrate overlap of this gene signature with the altered gene expression signature seen in EoE patient biopsy tissue. EPIT therapy response is associated with significant enrichment in pathways related to T-cell receptor signalling (P = 1.16 × 10-14), antigen presentation and costimulation, and cytokine signalling (P = 1.11 × 10-16), as well as upregulation of genes associated with regulatory T-cell function. CONCLUSIONS EoE is associated with distinct global transcriptional changes in CD4+ T cells, one feature of which is an IFN response signature. Clinically favorable response to EPIT is likely multifactorial but is associated with a distinct transcriptional profile in peripheral CD4+ cells supporting the hypothesis that EPIT alters peripheral CD4+ responses in EoE patients.
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Affiliation(s)
- Melanie A Ruffner
- Division of Allergy and ImmunologyThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of PediatricsThe Perelman School of Medicine at University of PennsylvaniaPhiladelphiaPAUSA
| | - Zhe Zhang
- Department of Biomedical and Health InformaticsThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Kelly Maurer
- Division of Allergy and ImmunologyThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Amanda B Muir
- Department of PediatricsThe Perelman School of Medicine at University of PennsylvaniaPhiladelphiaPAUSA
- Division of Gastroenterology, Hepatology, and NutritionThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Antonella Cianferoni
- Division of Allergy and ImmunologyThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of PediatricsThe Perelman School of Medicine at University of PennsylvaniaPhiladelphiaPAUSA
| | - Kathleen E Sullivan
- Division of Allergy and ImmunologyThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of PediatricsThe Perelman School of Medicine at University of PennsylvaniaPhiladelphiaPAUSA
| | - Jonathan M Spergel
- Division of Allergy and ImmunologyThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of PediatricsThe Perelman School of Medicine at University of PennsylvaniaPhiladelphiaPAUSA
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14
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Lucendo AJ, López-Sánchez P. Targeted Therapies for Eosinophilic Gastrointestinal Disorders. BioDrugs 2021; 34:477-493. [PMID: 32472465 DOI: 10.1007/s40259-020-00427-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The growing recognition of eosinophilic gastrointestinal disorders has revealed the limitations of current treatment (mainly based on dietary modification and corticosteroids), and include refractoriness, high recurrence rates, and the need for long-term therapy. Research efforts, mainly in eosinophilic esophagitis (EoE), have unveiled essential pathophysiological mechanisms leading to these disorders, which bear some similarities to those of atopic manifestations and are shared by eosinophilic gastroenteritis (EGE) and eosinophilic colitis (EC). Novel targeted therapies, some imported from bronchial asthma and atopic dermatitis, are currently being assessed in EoE. The most promising are monoclonal antibodies, including those targeting interleukin (IL)-13 (cendakimab) and IL-4 (dupilumab), with phase 3 trials currently ongoing. The potential of anti-integrin therapy (vedolizumab) and Siglec-8 blockers (antolimab) in EGE are also promising. Non-biological therapies for eosinophilic gut disorders, which include preventing the activation of Janus kinase (JAK)-signal transducer and activator of transcription (STAT) and chemoattractant receptor expressed on T helper 2 cells (CRTH2) signaling pathways, and other potential targets that deserve investigation in eosinophilic gut disorders, are reviewed.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos, s/n.,, 13700, Tomelloso, Ciudad Real, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain. .,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.
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15
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Mennini M, Tambucci R, Riccardi C, Rea F, De Angelis P, Fiocchi A, Assa'ad A. Eosinophilic Esophagitis and Microbiota: State of the Art. Front Immunol 2021; 12:595762. [PMID: 33679739 PMCID: PMC7933523 DOI: 10.3389/fimmu.2021.595762] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 01/04/2021] [Indexed: 12/12/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic, food-triggered, immune-mediated disease of the oesophagus, clinically characterized by symptoms referred to oesophagal dysfunction, and histologically defined by an eosinophil productive inflammation of the oesophagal mucosa, among other cell types. The involvement of an adaptive Th2-type response to food antigens in EoE was known since 2000; several cytokines and chemokines promote food-specific responses, during which local production of IgE, but also IgG4 derived from plasma cells in lamina propria of oesophagal mucosa might play an important role. Evidence pointing towards a possible role for the innate immunity in EoE has arisen recently. Together, this evidence gives rise to a potential role that the innate immune system in general, and also the microbial pattern recognition receptors (PRRs) might play in EoE pathogenesis. Among PRRs, Toll-like receptors (TLRs) are type-I transmembrane receptors expressed both on epithelial and lamina propria cells with the capacity to distinguish between pathogen and commensal microbes. As TLRs in the different intestinal epithelia represent the primary mechanism of epithelial recognition of bacteria, this evidence underlines that oesophagal TLR-dependent signaling pathways in EoE support the potential implication of microbiota and the innate immune system in the pathogenesis of this disease. The oesophagal mucosa hosts a resident microbiota, although in a smaller population as compared with other districts of the gastrointestinal tract. Few studies have focused on the composition of the microbiota of the normal oesophagus alone. Still, additional information has come from studies investigating the oesophagal microbiota in disease and including healthy patients as controls. Our review aims to describe all the evidence on the oesophagal and intestinal microbiota in patients with EoE to identify the specific features of dysbiosis in this condition.
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Affiliation(s)
- Maurizio Mennini
- Division of Allergy, Bambino Gesù Children's Hospital-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Carla Riccardi
- Division of Allergy, Bambino Gesù Children's Hospital-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesca Rea
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Paola De Angelis
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Alessandro Fiocchi
- Division of Allergy, Bambino Gesù Children's Hospital-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Amal Assa'ad
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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16
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Ghisa M, Laserra G, Maniero D, Marabotto E, Barberio B, Pelizzaro F, Barbuscio I, Zingone F, Savarino V, Savarino E. Eosinophilic esophagitis: from pathophysiology to management. Minerva Gastroenterol (Torino) 2020; 68:40-48. [PMID: 33267562 DOI: 10.23736/s2724-5985.20.02780-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Eosinophilic esophagitis (EoE) incidence and prevalence have sharply increased in the last decade; so, the management of these patients is changing rapidly. Standard regimens as elimination diet, proton pump inhibitors and topical swallowed steroids are not able to achieve remission in all patients. Moreover, loss of efficacy and safety concerns for long-term medical treatments are rising questions. As for other chronic immune-mediated diseases, biologics have been evaluated for the treatment of EoE. Several targets in the Th2-mediated inflammatory cascade with eosinophilic mucosal infiltration, have been tested with alternating results. This review provides a comprehensive discussion of the available studies evaluating biologics in EoE and the possible future options most desirable for these patients.
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Affiliation(s)
- Matteo Ghisa
- Unit of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua, Italy -
| | - Giorgio Laserra
- Unit of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua, Italy
| | - Daria Maniero
- Unit of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua, Italy
| | - Elisa Marabotto
- Unit of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Brigida Barberio
- Unit of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua, Italy
| | - Filippo Pelizzaro
- Unit of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua, Italy
| | - Ilenia Barbuscio
- Unit of Gastroenterology, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Fabiana Zingone
- Unit of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua, Italy
| | - Vincenzo Savarino
- Unit of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Edoardo Savarino
- Unit of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
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17
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Wen T, Rothenberg ME. Cell-by-cell deciphering of T cells in allergic inflammation. J Allergy Clin Immunol 2020; 144:1143-1148. [PMID: 31703761 DOI: 10.1016/j.jaci.2019.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/30/2019] [Accepted: 10/01/2019] [Indexed: 12/28/2022]
Abstract
Technical advances in single-cell RNA sequencing (scRNA-seq) render it possible to examine the transcriptomes of single cells in patients with allergic inflammation with high resolution in the context of their specific microenvironment, treatment, and disease status. Using a recently published scRNA-seq study of tissue T cells as an example, we introduce the major pipeline steps, illustrate the options of scRNA-seq platforms, summarize new knowledge gained from this study, and provide directions for future research. The presented scRNA-seq study elucidated the T-cell heterogeneity present in an allergic inflammatory tissue focused on eosinophilic esophagitis, a prototypic, chronic, allergic disease, which provided a unique opportunity to probe the pathogenesis of allergic inflammation at the tissue level through readily available endoscopically procured biopsy specimens. scRNA-seq analysis identified 8 populations of CD3+ T cells and defined 2 disease-specific populations of CD3+CD4+ T cells, including a markedly activated type 2 cytokine-producing pathogenic cell population distinguished by expression of the short-chain fatty acid receptor free fatty acid receptor 3 and a population of regulatory T cells. In addition to presenting and interpreting new findings within the prior literature, we postulate about future single-cell next-generation sequencing platforms in this burgeoning field.
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Affiliation(s)
- Ting Wen
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati.
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18
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Wauters L, Burns G, Ceulemans M, Walker MM, Vanuytsel T, Keely S, Talley NJ. Duodenal inflammation: an emerging target for functional dyspepsia? Expert Opin Ther Targets 2020; 24:511-523. [PMID: 32249629 DOI: 10.1080/14728222.2020.1752181] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Functional dyspepsia (FD) is one of the most common functional gastrointestinal disorders and is classified into postprandial distress and epigastric pain syndrome. Despite the recognition of duodenal inflammation as a potential trigger of symptoms, only limited anti-inflammatory therapies exist.Areas covered: This narrative review summarizes the recent advances in the pathophysiology and treatment of FD; it identifies potential therapeutic targets and gaps in the field. An electronic literature search was conducted in Pubmed up to 31st of December 2019.Expert opinion: There is compelling evidence for the role of duodenal inflammation and the eosinophil-mast cell axis in the pathogenesis of dyspeptic symptoms. Traditional prokinetic drugs and neuromodulators target gastric dysmotility and visceral hypersensitivity but are hampered by limited efficacy and side effects. Independent of acid suppression, the anti-inflammatory action of proton pump inhibitors, which remain the first-line therapy in FD, may also explain their therapeutic effect. Other existing and newly established anti-inflammatory drugs should be investigated while trials including probiotics and selective antibiotics should examine the host microbiome and immune activation. Targeted treatments for potential causes of duodenal pathology, such as impaired permeability and dysbiosis, are likely to emerge in the future.
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Affiliation(s)
- Lucas Wauters
- Translational Research in Gastrointestinal Diseases (TARGID), KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Grace Burns
- Faculty of Health and Medicine, University of Newcastle and Hunter Medical Research Institute, Callaghan, Australia
| | - Matthias Ceulemans
- Translational Research in Gastrointestinal Diseases (TARGID), KU Leuven, Leuven, Belgium
| | - Marjorie M Walker
- Faculty of Health and Medicine, University of Newcastle and Hunter Medical Research Institute, Callaghan, Australia
| | - Tim Vanuytsel
- Translational Research in Gastrointestinal Diseases (TARGID), KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Simon Keely
- Faculty of Health and Medicine, University of Newcastle and Hunter Medical Research Institute, Callaghan, Australia.,Vaccine and Asthma (VIVA) Program, Hunter Medical Research Institute, Callaghan, Australia
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle and Hunter Medical Research Institute, Callaghan, Australia
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19
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Lucendo AJ. Pharmacological treatments for eosinophilic esophagitis: current options and emerging therapies. Expert Rev Clin Immunol 2020; 16:63-77. [PMID: 31842634 DOI: 10.1080/1744666x.2019.1705784] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: The epidemiology of eosinophilic esophagitis (EoE) has increased rapidly to represent a common cause of chronic and recurrent esophageal symptoms. Current treatment options have limitations so the development of novel therapies is a matter of growing interest.Areas covered: This article provides an up-to-date discussion of current therapies and investigational options for EoE. Established anti-inflammatory treatments for EoE at present include dietary therapy, proton pump inhibitors and swallowed topic steroids, which should be combined with endoscopic dilation in case of strictures. Refractoriness, high recurrence rates, and need for long-term therapies have promoted the investigation of novel, esophageal-targeted formulas of topic corticosteroids, and monoclonal antibodies (including mepolizumab, reslizumab, QAX576, RPC4046, dupilumab, omalizumab, infliximab, and vedolizumab) for EoE, with some having been demonstrated as effective and safe in the short term. Several additional promising therapies are also discussed.Expert opinion: Several therapeutic targets have shown efficacy and will be approved to treat EoE, especially corticosteroid-sparing options and those for patients with multiple Th2-associated diseases. Personalized therapeutic strategies for initial and maintenance treatments of EoE must be rationally designed, to reduce the burden of disease and answer meaningfully the needs of all stakeholders involved in EoE.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
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20
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Future therapies for eosinophilic gastrointestinal disorders. Ann Allergy Asthma Immunol 2019; 124:219-226. [PMID: 31778820 DOI: 10.1016/j.anai.2019.11.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To review novel therapeutics in development for treatment of eosinophilic gastrointestinal disorders (EGIDs). DATA SOURCES Clinical trial data (clinicaltrials.gov) and literature search on PubMed. STUDY SELECTIONS Studies on treatment and clinical trials in EGIDs were included in this review. RESULTS During the past decade, significant progress has been made in understanding disease mechanisms in EGIDs. As a result, a variety of novel therapeutics have been developed for treatment of these disorders. Several monoclonal antibodies against targets, including interleukin (IL) 4, IL-5, IL-13, integrins, and siglec-8, have shown promise in early trials. Novel formulations of corticosteroids are also in development. CONCLUSION The field of EGID research has advanced rapidly, and disease-modifying therapeutics are closer to clinical application.
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Cavalli E, Brusaferro A, Pieri ES, Cozzali R, Farinelli E, De' Angelis GL, Esposito S. Eosinophilic esophagitis in children: doubts and future perspectives. J Transl Med 2019; 17:262. [PMID: 31399124 PMCID: PMC6688237 DOI: 10.1186/s12967-019-2014-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/04/2019] [Indexed: 01/07/2023] Open
Abstract
Background Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disorder and represents the leading cause of food impaction. The pathogenesis of EoE is the result of an interplay between genetic, environmental and host immune system factors. New therapeutic approaches for EoE have been proposed. In this manuscript we review the current evidence regarding EoE management in pediatric age, with a particular focus on new findings related to the efficacy and safety of monoclonal antibodies. Main body Conventional therapies have failed in treating some patients with EoE, which then requires aggressive procedures such as esophageal dilatation. The most effective available medical therapy for EoE is swallowed topic corticosteroids (fluticasone propionate and budesonide), which have two main drawbacks: they are related to well-known adverse effects (especially in the paediatric population), and there are not enough long-term data to confirm that they are able to reverse the remodelling process of the esophageal mucosa, which is the major cause of EoE symptoms (including dysphagia, abdominal pain, nausea, obstruction, perforation and vomiting). The monoclonal antibodies appear to be an interesting therapeutic approach. However, the studies conducted until now have shown substantial histological improvement not coupled with significant clinical improvements and no significant relationship between a decreasing number of eosinophils and clinical symptoms, highlighting the importance in the pathogenesis of EoE of cells such as T-helper cells, mast cells, B cells, epithelial cells and natural killer cells. Conclusions Monoclonal antibodies targeting a signal involved in the pathogenesis of EoE may not break the complex self-propagating inflammatory activation responsible for perpetuation of the inflammatory response and the development of symptoms and complications. We speculate that combined biological therapies targeting more than one molecule or cell may provide better results, with conventional therapies potentially enhancing the effects of antibodies. However, further studies should aim to find the best therapeutic approach to target the cells involved in the remodelling process and to reverse the histological changes in this complex clinical condition.
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Affiliation(s)
- Elena Cavalli
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Andrea Brusaferro
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Elena Sofia Pieri
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Rita Cozzali
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Edoardo Farinelli
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Gian Luigi De' Angelis
- Gastroenterology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy.
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22
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Arias Á, Lucendo AJ. Molecular basis and cellular mechanisms of eosinophilic esophagitis for the clinical practice. Expert Rev Gastroenterol Hepatol 2019; 13:99-117. [PMID: 30791784 DOI: 10.1080/17474124.2019.1546120] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, allergen-driven inflammatory esophageal disease characterized by predominantly eosinophilic inflammation leading to esophageal dysfunction. Recent efforts to understand EoE have increased our knowledge of the disease. Areas covered: Multiple cells, molecules, and genes interplay with early life environmental factors in the pathophysiology of EoE to converge in the esophageal epithelium at the center of disease pathogenesis. Epithelial cells constitute a mayor cytokine source for TSLP and Calpain-14; an impaired epithelial barrier function allowing penetration of food and microbiota-derived antigens is involved in triggering and maintaining inflammation. Eosinophil and mast cell-derived products, including TGFβ, together with IL-1β and TNFα, promote epithelial mesenchymal transition in EoE, contributing to tissue remodeling by synthetizing and depositing extracellular matrix in subepithelial layers. This article aims to provide a state-of-the-art update on the pathophysiology of EoE applied to clinical practice, and latest research and developments with potential interest to improve the diagnosis and treatment of patients with EoE are revised. Expert commentary: Preliminary approaches have provided promising results toward incorporating minimally invasive methods for patient diagnosis and monitoring in clinical practice. Early diagnosis and optimized therapies will allow for personalized medicine in EoE.
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Affiliation(s)
- Ángel Arias
- a Research Unit , Hospital General La Mancha Centro , Alcázar de San Juan , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain
| | - Alfredo J Lucendo
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain.,c Department of Gastroenterology , Hospital General de Tomelloso , Ciudad Real , Spain
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Abstract
Recent studies have reported a higher prevalence of eosinophilic esophagitis in children with esophageal atresia. Under recognition of eosinophilic esophagitis in these patients may lead to excessive use of antireflux therapy and an escalation of interventions, including fundoplication, as symptoms may be attributed to gastroesophageal reflux disease. In addition, long-term untreated eosinophilic esophagitis may lead to recurrent strictures due to transmural esophageal inflammation, necessitating repeated dilatations. Eosinophilic esophagitis should be considered when children with esophageal atresia show persistent symptoms on standard antireflux treatment, increasing dysphagia, and recurrent strictures. Treatment has been found to not only significantly reduce intraepithelial eosinophil count, but also to improve symptoms, and to lower the occurrence of strictures and the need for dilatations. Future prospective studies are warranted in this area.
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Affiliation(s)
- Usha Krishnan
- Department of Pediatric Gastroenterology, Sydney Children's Hospital, Sydney, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
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24
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Eskian M, Khorasanizadeh M, Assa'ad AH, Rezaei N. Monoclonal Antibodies for Treatment of Eosinophilic Esophagitis. Clin Rev Allergy Immunol 2018; 55:88-98. [PMID: 29234969 DOI: 10.1007/s12016-017-8659-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus affecting both children and adults, with debilitating and progressive symptoms. EoE has shown an explosive epidemiological rise in the past few decades. Many patients experience a poor level of disease control despite maximal use of available guideline-based therapies, which seriously hampers their quality of life. Diet restrictions and systemic and topical corticosteroids are the current mainstays of EoE therapy, but are associated with significant efficacy, treatment compliance, and safety issues such as oral or esophageal candidiasis, growth retardation, osteopenia, osteoporosis, glucose intolerance, and cataract formation. As EoE is a chronic inflammatory disease, immune cells and cytokines are responsible for the inflammatory response and symptoms. Monoclonal antibodies specifically targeting these pathophysiologic effectors offer more potent relief of histologic and clinical disease features while keeping off-target adverse effects to a minimum. Herein, we have reviewed the current evidence regarding efficacy and safety of monoclonal antibodies including mepolizumab (anti-IL-5), reslizumab (anti-IL-5), QAX576 (anti-IL-13), omalizumab (anti-immunoglobulin-E), and infliximab (anti-TNF-α) in treatment of EoE. Our review indicates that although the use of monoclonal antibodies for EoE treatment is safe with limited and reversible adverse events, however, it is not yet possible to reach a final verdict on the efficacy of mAbs in EoE. Future well-designed studies are needed to clarify the exact role of mAbs in EoE.
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Affiliation(s)
- Mahsa Eskian
- Molecular Immunology Research Center, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - MirHojjat Khorasanizadeh
- Molecular Immunology Research Center, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Amal H Assa'ad
- Division of Allergy and Immunology, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Dr. Qarib St, Keshavarz Blvd, Tehran, 14194, Iran. .,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. .,Systematic Review and Meta-analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Boston, MA, USA.
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25
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Lu S, Herzlinger M, Cao W, Noble L, Yang D, Shapiro J, Kurtis J, LeLeiko N, Resnick M. Utility of 15(S)-HETE as a Serological Marker for Eosinophilic Esophagitis. Sci Rep 2018; 8:14498. [PMID: 30266946 PMCID: PMC6162315 DOI: 10.1038/s41598-018-32944-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/19/2018] [Indexed: 12/30/2022] Open
Abstract
The pathogenesis of eosinophilic esophagitis (EoE) involves Th2-mediated eosinophil recruitment and degranulation into the esophagus. However, measuring serum Th2 cytokines, eosinophils, and eosinophil-derived products does not reliably distinguish EoE from control populations. Non-invasive methods to diagnose EoE are lacking. We evaluated the diagnostic value of a novel candidate biomarker of EoE: 15(S)-hydroxyeicosatetraenoic acid (HETE). We used immunoassay to measure 15(S)-HETE and cytokine profiles in patients undergoing endoscopy with known or suspected EoE. 31 subjects were enrolled, 16 with EoE, and 15 with an alternate diagnosis. 15(S)-HETE was elevated in the EoE group compared to non-EoE group. The sensitivity and specificity of 15(S)-HETE to be used as a non-invasive marker is 50% and 80%, respectively. 15(S)-HETE may aid in the diagnosis of EoE.
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Affiliation(s)
- Shaolei Lu
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, USA.
| | - Michael Herzlinger
- Division of Pediatric Gastroenterology, Nutrition, and Liver Diseases, Hasbro Children's Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| | - Weibiao Cao
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| | - Lelia Noble
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| | - Dongfang Yang
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| | - Jason Shapiro
- Division of Pediatric Gastroenterology, Nutrition, and Liver Diseases, Hasbro Children's Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| | - Jonathan Kurtis
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| | - Neal LeLeiko
- Division of Pediatric Gastroenterology, Nutrition, and Liver Diseases, Hasbro Children's Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| | - Murray Resnick
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, USA
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26
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Hines BT, Rank MA, Wright BL, Marks LA, Hagan JB, Straumann A, Greenhawt M, Dellon ES. Minimally invasive biomarker studies in eosinophilic esophagitis: A systematic review. Ann Allergy Asthma Immunol 2018; 121:218-228. [PMID: 29753832 PMCID: PMC6104633 DOI: 10.1016/j.anai.2018.05.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/01/2018] [Accepted: 05/08/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic, inflammatory disease of the esophagus that currently requires repeated endoscopic biopsies for diagnosis and monitoring because no reliable noninvasive markers have been identified. OBJECTIVE To identify promising minimally invasive EoE biomarkers and remaining gaps in biomarker validation. METHODS We performed a systematic review of EMBASE, Ovid MEDLINE, PubMed, and Web of Science from inception to June 6, 2017. Studies were included if patients met the 2007 consensus criteria for EoE diagnosis, a minimally invasive biomarker was assessed, and the study included at least 1 control for comparison. RESULTS The search identified 2094 studies, with 234 reviewed at full-text level, and 49 included in the analysis (20 adult, 19 pediatric, 7 pediatric and adult, and 3 not stated). Most (26 of 49) were published after 2014. Thirty-five studies included healthy controls, 9 analyzed atopic controls, and 29 compared samples from patients with active and inactive EoE. Minimally invasive biomarkers were obtained from peripheral blood (n = 41 studies), sponge or string samples (n = 3), oral or throat swab secretions (n = 2), breath condensate (n = 2), stool (n = 2), and urine (n = 2). The most commonly reported biomarkers were peripheral blood eosinophils (n = 16), blood and string eosinophil granule proteins (n = 14), and eosinophil surface or intracellular markers (n = 12). EoE biomarkers distinguished active EoE from healthy controls in 23 studies, atopic controls in 2 studies, and inactive EoE controls in 20 studies. CONCLUSION Several promising minimally invasive biomarkers for EoE have emerged; however, few are able to differentiate EoE from other atopic diseases.
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Affiliation(s)
- Brittany T Hines
- Division of Allergy, Asthma and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona; Phoenix Children's Hospital, Phoenix, Arizona.
| | - Matthew A Rank
- Division of Allergy, Asthma and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona; Phoenix Children's Hospital, Phoenix, Arizona
| | - Benjamin L Wright
- Division of Allergy, Asthma and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona; Phoenix Children's Hospital, Phoenix, Arizona
| | - Lisa A Marks
- Mayo Clinic Libraries, Mayo Clinic, Scottsdale, Arizona
| | - John B Hagan
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Matthew Greenhawt
- Department of Pediatrics Allergy Section, Children's Hospital Colorado, University of Colorado School of Medicine Aurora, Colorado
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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27
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Wechsler JB, Hirano I. Biological therapies for eosinophilic gastrointestinal diseases. J Allergy Clin Immunol 2018; 142:24-31.e2. [PMID: 29859203 DOI: 10.1016/j.jaci.2018.05.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/24/2018] [Accepted: 05/24/2018] [Indexed: 02/06/2023]
Abstract
The scientific basis and the clinical application of mAb therapies that target specific immunologic pathways for eosinophilic gastrointestinal diseases are areas of active interest. There is a growing recognition of a subset of patients with eosinophilic esophagitis whose disease does not respond well to topical steroids or elimination diets. In addition, long-term use of corticosteroids presents possible risks that are currently being evaluated. Systemic therapy with a biologic agent offers potential advantages as a global approach that could limit the need for multiple, locally active medical therapies and allergen avoidance. The identification of novel biologic strategies is ongoing, and the recent validation of instruments and outcome measures to assess disease activity has proved essential in demonstrating efficacy. Studies using biologics that target IL-13 pathways in the treatment of eosinophilic esophagitis have demonstrated substantial promise.
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Affiliation(s)
- Joshua B Wechsler
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill.
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Ill
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28
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Toll-like receptors-mediated pathways activate inflammatory responses in the esophageal mucosa of adult eosinophilic esophagitis. Clin Transl Gastroenterol 2018; 9:147. [PMID: 29691386 PMCID: PMC5915448 DOI: 10.1038/s41424-018-0017-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/16/2018] [Accepted: 02/22/2018] [Indexed: 12/19/2022] Open
Abstract
Objectives Esophageal microbiota and regulation of adaptive immunity are increasingly being investigated in eosinophilic esophagitis (EoE). Toll-like receptors (TLRs) play a central role in the initiation and maintenance of innate immune activity. Our objective was to characterize the esophageal and duodenal innate immune response in EoE and its modulation by dietary therapy. Methods Esophageal and duodenal biopsy samples were collected from 10 adults with untreated EoE, before and after effective treatment with a six-food elimination diet (SFED), and 10 controls with normal esophagus. In all cases, bacterial load (by mRNA expression of 16S), TLRs, mucins, transcription factors, interleukins, components of the NKG2D system, and innate immunity effectors were assessed by qPCR. Protein expression of TLRs were also determined by immunofluorescence. Results Bacterial load and TLR1, TLR2, TLR4, and TLR9 were overexpressed on biopsies with active EoE compared with controls. Muc1 and Muc5B genes were downregulated while Muc4 was overexpressed. Upregulation of MyD88 and NFκB was found together with IL-1β, IL-6, IL-8, and IL-10 mediators and PER-1, iNOS, and GRZA effectors. NG-K2D components (KLRK1, IL-15, MICB) were also upregulated. In all cases, changes in active EoE were normalized following SFED and mucosal healing. Duodenal samples also showed increased expressions of TLR-1, TLR-2, and TLR-4, but not 16S or any other mediators nor effectors of inflammation. Conclusions Esophageal TLR-dependent signaling pathways in EoE support the potential implication of microbiota and the innate immune system in the pathogenesis of this disease.
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29
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Cianferoni A, Ruffner MA, Guzek R, Guan S, Brown-Whitehorn T, Muir A, Spergel JM. Elevated expression of activated T H2 cells and milk-specific T H2 cells in milk-induced eosinophilic esophagitis. Ann Allergy Asthma Immunol 2017; 120:177-183.e2. [PMID: 29289462 DOI: 10.1016/j.anai.2017.11.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is an allergic inflammatory disease that is triggered by food allergens and characterized by progressive esophageal dysfunction. Esophageal biopsy specimens are characterized by eosinophilia and expression of TH2 cytokines. OBJECTIVE To ascertain whether TH2 cells can exist in the peripheral blood in patients with milk-induced EoE. METHODS Peripheral blood mononuclear cells from 20 children with milk-induced EoE were collected during active EoE (EoE-A) while consuming milk and inactive EoE (EoE-I) while not consuming milk, and 8 healthy patients without EoE were used as controls. The samples were analyzed for T-cell phenotype, including intracellular cytokines before and after incubation with milk antigens and assessed by flow cytometry. RESULTS We found a significant increase in CD4+ TH2 cells in the peripheral blood of patients with EoE-A compared with the controls. Furthermore, we observed a significant mean (SD) increase in the activation marker of CD154+ T cells (0.17% [0.047%]) in patients with EoE-A compared with control patients (0.034% [0.007%]) and EoE-I (0.025% [0.008]). These CD4+ T cells expressed significantly increase levels of TH2 cytokines (interleukins 4, 5, and 13) compared with the EoE-I and control groups. CD3+CD4+CD154+IL-5+ cells were significantly increased by milk antigens in both milk-induced EoE-A (0.050% [0.008%] to 0.079% [0.017%]) and EoE-I (0.0045% [0.002%] to 0.014% [0.008%]) compared with the controls (0.008% [0.003%] to 0.003% [0.001%]). CONCLUSION Our findings indicate that in EoE peripheral T cells have specific activation to milk allergens.
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Affiliation(s)
- Antonella Cianferoni
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melanie A Ruffner
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ryan Guzek
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shaobo Guan
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Terri Brown-Whitehorn
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amanda Muir
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jonathan M Spergel
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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30
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Warners MJ, van Rhijn BD, Verheij J, Smout AJPM, Bredenoord AJ. Disease activity in eosinophilic esophagitis is associated with impaired esophageal barrier integrity. Am J Physiol Gastrointest Liver Physiol 2017; 313:G230-G238. [PMID: 28546282 DOI: 10.1152/ajpgi.00058.2017] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/19/2017] [Accepted: 05/19/2017] [Indexed: 01/31/2023]
Abstract
In eosinophilic esophagitis (EoE), the esophageal barrier integrity is impaired. Integrity can be assessed with different techniques. To assess the correlations between esophageal eosinophilia and various measures of mucosal integrity and to evaluate whether endoscopic impedance measurements can predict disease activity, endoscopies and mucosal integrity measurements were performed in adult EoE patients with active disease (≥15 eosinophils/high-power field) at baseline (n = 32) and after fluticasone (n = 15) and elemental dietary treatment (n = 14) and in controls (n = 19). Mucosal integrity was evaluated during endoscopy using electrical tissue spectroscopy (ETIS) measuring mucosal impedance and transepithelial electrical resistance (TER) and transepithelial molecule-flux through biopsy specimens in Ussing chambers. We included 61 measurements; 32 of patients at baseline and 29 after treatment, 3 patients dropped out. After treatment, 20 patients were in remission (≤15 eosinophils/high-power field) and these measurements were compared with 41 measurements of patients with active disease (at baseline or after failed treatment). All four mucosal integrity measures showed significant impairment in active EoE compared with remission. Eosinophilia was negatively correlated with ETIS and TER and positively with transepithelial molecule flux (P ≤ 0.001). The optimal ETIS cutoff to predict disease activity was 6,000 Ω·m with a sensitivity of 79% [95% confidence interval (CI) 54-94%], specificity of 84% (95% CI 69-94%), positive predictive values of 89% (95% CI 77-95%) and negative predictive values of 71% (95% CI 54-84%). In EoE patients, markers of mucosal integrity correlate with esophageal eosinophilia. Additionally, endoscopic mucosal impedance measurements can predict disease activity.NEW & NOTEWORTHY In adult patients with eosinophilic esophagitis (EoE), the mucosal integrity, measured by making use of four different parameters, correlates strongly with esophageal eosinophilia. The accuracy of endoscopically measured mucosal impedance to distinguish active disease from remission was acceptable with moderate specificity and sensitivity. Mucosal impedance measurements can predict disease activity in adult EoE patients.
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Affiliation(s)
- Marijn J Warners
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands; .,Tytgat Institute for Liver and GI Research, Academic Medical Centre, Amsterdam, The Netherlands
| | - Bram D van Rhijn
- Department of Dermatology and Allergology, University Medical Centre, Utrecht, The Netherlands; and
| | - Joanne Verheij
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Andreas J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
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31
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Nhu QM, Aceves SS. Tissue Remodeling in Chronic Eosinophilic Esophageal Inflammation: Parallels in Asthma and Therapeutic Perspectives. Front Med (Lausanne) 2017; 4:128. [PMID: 28831387 PMCID: PMC5549614 DOI: 10.3389/fmed.2017.00128] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/21/2017] [Indexed: 12/20/2022] Open
Abstract
Chronic eosinophilic inflammation is associated with tissue remodeling and fibrosis in a number of chronic T-helper 2 (Th2)-mediated diseases including eosinophilic esophagitis (EoE) and asthma. Chronic inflammation results in dysregulated tissue healing, leading to fibrosis and end organ dysfunction, manifesting clinically as irreversible airway obstruction in asthma and as esophageal rigidity, strictures, narrowing, dysmotility, dysphagia, and food impactions in EoE. Current therapies for EoE and asthma center on reducing inflammation-driven tissue remodeling and fibrosis with corticosteroids, coupled with symptomatic control and allergen avoidance. Additional control of Th2 inflammation can be achieved in select asthma patients with biologic therapies such as anti-IL-5 and anti-IL-13 antibodies, which have also been trialed in EoE. Recent molecular analysis suggests an emerging role for structural cell dysfunction, either inherited or acquired, in the pathogenesis and progression of EoE and asthma tissue remodeling. In addition, new data suggest that inflammation-independent end organ rigidity can alter structural cell function. Herein, we review emerging data and concepts for the pathogenesis of tissue remodeling and fibrosis primarily in EoE and relevant pathogenetic parallels in asthma, focusing additionally on emerging disease-specific therapies and the ability of these therapies to reduce tissue remodeling in subsets of patients.
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Affiliation(s)
- Quan M Nhu
- Scripps Translational Science Institute, The Scripps Research Institute, La Jolla, CA, United States.,Division of Gastroenterology and Hepatology, Department of Medicine, Scripps Clinic - Scripps Green Hospital, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Medicine, Scripps Clinic-Scripps Green Hospital, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Seema S Aceves
- Division of Allergy and Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, United States.,Rady Children's Hospital - San Diego, San Diego, CA, United States
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32
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Blanchard C, Simon D, Schoepfer A, Straumann A, Simon HU. Eosinophilic esophagitis: unclear roles of IgE and eosinophils. J Intern Med 2017; 281:448-457. [PMID: 28425585 DOI: 10.1111/joim.12568] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the oesophagus. Recognized as a distinct entity only two decades ago, the emergence of the disease along with the availability of new technologies has rapidly opened new research avenues and outlined the main features of the pathogenesis of EoE. Yet, each advance in our understanding of the disease has raised new questions about the previous consensus. Currently, new subsets of the disease challenge our diagnostic criteria. For instance, it was believed that EoE did not respond to proton pump inhibitor (PPI) therapy; however, it has now been shown that a substantial proportion of EoE patients indeed respond to PPIs. In addition, a new subset of patients not even presenting eosinophil infiltrates in the oesophagus has also been described. Moreover, approaches for better understanding the heritability of the disease bring into question the dogma of predominant genetic involvement. Furthermore, the specificity and sensitivity of allergy testing for targeted food avoidance is highly controversial, and the production of specific antibodies in EoE now includes IgG4 in addition to IgE. In conclusion, EoE is perceived as 'a moving target' and the aim of this review was to summarize the current understanding of EoE pathogenesis.
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Affiliation(s)
- C Blanchard
- Nestlé Research Center, Lausanne, Switzerland
| | - D Simon
- Department of Dermatology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - A Schoepfer
- Division of Gastroenterology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - A Straumann
- Swiss EoE Clinic and EoE Research Network, Olten, Switzerland
| | - H-U Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland
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Lingblom C, Wallander J, Ingelsten M, Bergquist H, Bove M, Saalman R, Welin A, Wennerås C. Eosinophils from eosinophilic oesophagitis patients have T cell suppressive capacity and express FOXP3. Clin Exp Immunol 2017; 187:455-465. [PMID: 27921303 PMCID: PMC5290232 DOI: 10.1111/cei.12898] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/21/2016] [Accepted: 11/02/2016] [Indexed: 01/07/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is an antigen-driven T cell-mediated chronic inflammatory disease where food and environmental antigens are thought to have a role. Human eosinophils express the immunoregulatory protein galectin-10 and have T cell suppressive capacity similar to regulatory T cells (Tregs ). We hypothesized that one function of eosinophils in EoE might be to regulate the T cell-driven inflammation in the oesophagus. This was tested by evaluating the suppressive capacity of eosinophils isolated from the blood of adult EoE patients in a mixed lymphocyte reaction. In addition, eosinophilic expression of forkhead box protein 3 (FOXP3), the canonical transcription factor of Tregs , was determined by conventional and imaging flow cytometry, quantitative polymerase chain reaction (qPCR), confocal microscopy and immunoblotting. It was found that blood eosinophils from EoE patients had T cell suppressive capacity, and that a fraction of the eosinophils expressed FOXP3. A comparison of EoE eosinophils with healthy control eosinophils indicated that the patients' eosinophils had inferior suppressive capacity. Furthermore, a higher percentage of the EoE eosinophils expressed FOXP3 protein compared with the healthy eosinophils, and they also had higher FOXP3 protein and mRNA levels. FOXP3 was found in the cytosol and nucleus of the eosinophils from both the patients and healthy individuals, contrasting with the strict nuclear localization of FOXP3 in Tregs . To conclude, these findings suggest that the immunoregulatory function of eosinophils may be impaired in EoE.
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Affiliation(s)
- C. Lingblom
- Department of Infectious DiseasesHead and Neck Surgery, Sahlgrenska Academy, University of GothenburgGöteborgSweden
| | - J. Wallander
- Department of Infectious DiseasesHead and Neck Surgery, Sahlgrenska Academy, University of GothenburgGöteborgSweden
| | - M. Ingelsten
- Department of Infectious DiseasesHead and Neck Surgery, Sahlgrenska Academy, University of GothenburgGöteborgSweden
| | - H. Bergquist
- Department of ENTHead and Neck Surgery, Sahlgrenska Academy, University of GothenburgGöteborgSweden
| | - M. Bove
- Department of ENTHead and Neck Surgery, NÄL HospitalTrollhättanSweden
| | - R. Saalman
- Department of PediatricsInstitution of Clinical Sciences, Sahlgrenska Academy, University of GothenburgGöteborgSweden
| | - A. Welin
- Department of Rheumatology and Inflammation ResearchSahlgrenska Academy, University of GothenburgGöteborgSweden
| | - C. Wennerås
- Department of Infectious DiseasesHead and Neck Surgery, Sahlgrenska Academy, University of GothenburgGöteborgSweden
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Moawad FJ, Cheng E, Schoepfer A, Al-Haddad S, Bellizzi AM, Dawson H, El-Zimaity H, Guindi M, Penagini R, Safrooneva E, Chehade M. Eosinophilic esophagitis: current perspectives from diagnosis to management. Ann N Y Acad Sci 2016; 1380:204-217. [DOI: 10.1111/nyas.13164] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/01/2016] [Accepted: 06/03/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Fouad J. Moawad
- Gastroenterology Service, Department of Medicine; Walter Reed National Military Medical Center; Bethesda Maryland
| | - Edaire Cheng
- Pediatric Gastroenterology, Hepatology & Nutrition Division; University of Texas Southwestern Medical Center; Dallas Texas
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology; Centre Hospitalier Universitaire; Vaudois/CHUV Lausanne Switzerland
| | - Sahar Al-Haddad
- Department of Laboratory Medicine; St. Michael's Hospital; Hamilton Ontario Canada
| | - Andrew M. Bellizzi
- Department of Pathology; University of Iowa Hospitals and Clinics, University of Iowa Carver College of Medicine; Iowa City Iowa
| | - Heather Dawson
- Institute of Pathology; University of Bern; Bern Switzerland
| | | | - Maha Guindi
- Department of Pathology and Laboratory Medicine; Cedars-Sinai Medical Center; Los Angeles California
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, and Department of Pathophysiology and Transplantation; Università degli Studi; Milan Italy
| | - Ekaterina Safrooneva
- Institute of Social and Preventive Medicine; University of Bern; Bern Switzerland
| | - Mirna Chehade
- Department of Pediatrics and Medicine, Mount Sinai Center for Eosinophilic Disorders; Icahn School of Medicine at Mount Sinai; New York New York
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35
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Hill DA, Spergel JM. The Immunologic Mechanisms of Eosinophilic Esophagitis. Curr Allergy Asthma Rep 2016; 16:9. [PMID: 26758862 DOI: 10.1007/s11882-015-0592-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease that is triggered by food and/or environmental allergens and is characterized by a clinical and pathologic phenotype of progressive esophageal dysfunction due to tissue inflammation and fibrosis. EoE is suspected in patients with painful swallowing, among other symptoms, and is diagnosed by the presence of 15 or more eosinophils per high-power field in one or more of at least four esophageal biopsy specimens. The prevalence of EoE is increasing and has now reached rates similar to those of other chronic gastrointestinal disorders such as Crohn's disease. In recent years, our understanding of the immunologic mechanisms underlying this condition has grown considerably. Thanks to new genetic, molecular, cellular, animal, and translational studies, we can now postulate a detailed pathway by which exposure to allergens results in a complex and coordinated type 2 inflammatory cascade that, if not intervened upon, can result in pain on swallowing, esophageal strictures, and food impaction. Here, we review the most recent research in this field to synthesize and summarize our current understanding of this complex and important disease.
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Affiliation(s)
- David A Hill
- Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Allergy and Immunology, The Children's Hospital of Philadelphia, 3550 Market St., Philadelphia, PA, 19104, USA
| | - Jonathan M Spergel
- Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Division of Allergy and Immunology, The Children's Hospital of Philadelphia, 3550 Market St., Philadelphia, PA, 19104, USA.
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Morris DW, Stucke EM, Martin LJ, Abonia JP, Mukkada VA, Putnam PE, Rothenberg ME, Fulkerson PC. Eosinophil progenitor levels are increased in patients with active pediatric eosinophilic esophagitis. J Allergy Clin Immunol 2016; 138:915-918.e5. [PMID: 27199214 DOI: 10.1016/j.jaci.2016.03.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/19/2016] [Accepted: 03/02/2016] [Indexed: 01/07/2023]
Affiliation(s)
- David W Morris
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Emily M Stucke
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lisa J Martin
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - J Pablo Abonia
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Patricia C Fulkerson
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Hematopoietic prostaglandin D synthase defines a proeosinophilic pathogenic effector human TH2 cell subpopulation with enhanced function. J Allergy Clin Immunol 2016; 137:907-18.e9. [DOI: 10.1016/j.jaci.2015.08.007] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 08/01/2015] [Accepted: 08/06/2015] [Indexed: 01/03/2023]
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Guarino MPL, Cicala M, Behar J. Eosinophilic esophagitis: New insights in pathogenesis and therapy. World J Gastrointest Pharmacol Ther 2016; 7:66-77. [PMID: 26855813 PMCID: PMC4734956 DOI: 10.4292/wjgpt.v7.i1.66] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 08/17/2015] [Accepted: 12/02/2015] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a clinico-pathological entity with esophageal symptoms and dense esophageal eosinophilic infiltration throughout the esophagus that may persist despite treatment with proton pump inhibitors. This eosinophilic infiltration is usually absent in the stomach, small intestine and colon, although there are a number of reports of patients with a multi-organ involvement. EoE is associated with abnormalities involving TH2-dependent immunity, with multiple environmental factors strongly contributing to disease expression. The layer of the esophagus affected by the eosinophilic infiltration causes the specific symptoms. Esophageal involvement results mostly in dysphagia for solids that can be severe enough to cause recurrent esophageal obstruction with typical endoscopic features suggesting esophageal remodeling and pathological changes of eosinophilic infiltration of the mucosa, sub-epithelial fibrosis and muscle hypertrophy. This disease is frequently associated with other allergic conditions such as allergic asthma, allergic dermatitis and eosinophilia. The treatment of patients with EoE depends on the severity of the symptoms and of the inflammatory process as well as to their response to a gradual step-up treatment. The first line of treatment consists of steroid containing local inhalers. If unresponsive they are then treated with oral steroids. Intravenous interleukin blockers seem to have a consistent positive therapeutic effect.
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Elimination and elemental diet therapy in eosinophilic oesophagitis. Best Pract Res Clin Gastroenterol 2015; 29:793-803. [PMID: 26552778 DOI: 10.1016/j.bpg.2015.06.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 06/18/2015] [Indexed: 01/31/2023]
Abstract
Eosinophilic oesophagitis (EoE) is a chronic immune-mediated disorder of the oesophagus. The incidence of EoE has been raised substantially and EoE has recently become the most prevalent cause of dysphagia among the adolescents. Food and aeroallergens are believed to play a major role in the pathogenesis. Current treatment includes topical steroids and dietary therapy. Dietary therapy with elimination of causative allergens could provide a durable long-term solution. Dietary therapy in EoE consists of in elemental and empiric elimination diets. Elemental diet with amino acid-based formula is most effective in achieving disease remission but poor taste makes adherence challenging. Empiric elimination diet based on avoidance of most common food allergens offers moderate response rates, the usefulness of allergy test-directed elimination diets is questioned by low response rates. In conclusion, dietary treatments for EoE seem promising, but further refinement is required before it can become standard care.
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40
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Abstract
The mechanisms underlying eosinophilic esophagitis (EoE) have been intensely investigated, and significant advances have been made in understanding the pathogenesis of EoE. EoE is defined as a chronic immune/antigen-mediated disease, characterized clinically by symptoms of esophageal dysfunction and histologically by an esophageal eosinophilic infiltrate. In this paper, we will review the current knowledge of EoE pathophysiology based on both animal and human data and discuss possible etiologic mechanisms from the genetic and environmental perspectives. EoE is a Th2-predominant inflammatory process triggered by allergens. Proinflammatory cytokines and chemokines recruit eosinophils and other effector cells, such as mast cells, into the esophageal epithelium, where they cause direct damage and promote esophageal remodeling. The genetic expression profile of EoE has been described, and several single nucleotide polymorphisms have been identified and associated with EoE. While this genetic contribution is important, it is difficult to postulate that EoE is primarily a genetic disease. Given the rapid epidemiologic changes in the incidence and prevalence of EoE over the past two decades, environmental factors may be the driving force. While it is not known what causes EoE in an individual patient at a specific time, the current hypothesis is that there is a complex interaction between genetic factors and environmental exposures that remains to be elucidated.
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Affiliation(s)
- Thomas M. Runge
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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41
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Lingblom C, Bergquist H, Johnsson M, Sundström P, Quiding-Järbrink M, Bove M, Wennerås C. Topical corticosteroids do not revert the activated phenotype of eosinophils in eosinophilic esophagitis but decrease surface levels of CD18 resulting in diminished adherence to ICAM-1, ICAM-2, and endothelial cells. Inflammation 2015; 37:1932-44. [PMID: 24870064 DOI: 10.1007/s10753-014-9926-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Swallowed topical corticosteroids are the standard therapy for eosinophilic esophagitis (EoE) in adults. Eosinophils in the blood of untreated EoE patients have an activated phenotype. Our aim was to determine if corticosteroids restore the phenotype of eosinophils to a healthy phenotype and if certain cell-surface molecules on blood eosinophils correlate with eosinophilic infiltration of the esophagus. Levels of eight surface markers on eosinophils from treated and untreated EoE patients were determined by flow cytometry and analyzed using multivariate methods of pattern recognition. Corticosteroid-treated EoE patients' eosinophils had decreased levels of CD18 compared to both untreated patients and healthy controls, but maintained their activated phenotype. CD18 expression correlated positively with eosinophil numbers in the esophagus and promoted the adherence of eosinophils to ICAM-1, ICAM-2, and to endothelial cells. The diminished expression of CD18 may be one mechanism behind the reduced entry of eosinophils into the esophagus in corticosteroid-treated EoE patients.
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Affiliation(s)
- Christine Lingblom
- Department of Infectious Diseases, Sahlgrenska Academy, Gothenburg University, Guldhedsgatan 10A, 41346, Göteborg, Sweden,
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42
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Cheng E. Translating new developments in eosinophilic esophagitis pathogenesis into clinical practice. ACTA ACUST UNITED AC 2015; 13:30-46. [PMID: 25598233 DOI: 10.1007/s11938-014-0041-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OPINION STATEMENT New developments in eosinophilic esophagitis (EoE) pathogenesis are shaping our current therapeutic and management strategies. EoE is a chronic allergic inflammatory disease with progression to fibrostenotic disease. The disease warrants early diagnosis and long-term maintenance therapy. The diagnosis of EoE should be based on the concept of an allergy-mediated disease with esophageal dysfunction and esophageal eosinophilia. Recent findings suggest that proton pump inhibitor (PPI)-responsive esophageal eosinophilia (PPI-REE) is likely a continuum of EoE or a similar T-helper 2 (Th2)-mediated allergic process. PPIs have therapeutic properties that can benefit both gastroesophageal reflux disease (GERD) and EoE. Therefore, PPIs should be considered not a diagnostic tool but, rather, a therapeutic option for EoE. If patients are PPI nonresponsive, then dietary therapy or steroid therapy should be considered. Dilation can be reserved as adjuvant therapy for severe fibrostenotic lesions.
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Affiliation(s)
- Edaire Cheng
- Esophageal Diseases Center, Pediatric Gastroenterology, Department of Pediatrics, Children's Medical Center and the University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA,
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43
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Prussin C. Allergic Inflammatory Diseases of the Gastrointestinal Tract. Mucosal Immunol 2015. [DOI: 10.1016/b978-0-12-415847-4.00083-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Food allergy is defined as an adverse immune response towards food proteins or as a form of a food intolerance associated with a hypersensitive immune response. It should also be reproducible by a double-blind placebo-controlled food challenge. Many reported that food reactions are not allergic but are intolerances. Food allergy often presents to clinicians as a symptom complex. This review focuses on the clinical spectrum and manifestations of various forms of food allergies. According to clinical presentations and allergy testing, there are three types of food allergy: IgE mediated, mixed (IgE/Non-IgE), and non-IgE mediated (cellular, delayed type hypersensitivity). Recent advances in food allergy in early childhood have highlighted increasing recognition of a spectrum of delayed-onset non-IgE-mediated manifestation of food allergy. Common presentations of food allergy in infancy including atopic eczema, infantile colic, and gastroesophageal reflux. These clinical observations are frequently associated with food hypersensitivity and respond to dietary elimination. Non-IgE-mediated food allergy includes a wide range of diseases, from atopic dermatitis to food protein-induced enterocolitis and from eosinophilic esophagitis to celiac disease. The most common food allergies in children include milk, egg, soy, wheat, peanut, treenut, fish, and shellfish. Milk and egg allergies are usually outgrown, but peanut and treenut allergy tends to persist. The prevalence of food allergy in infancy is increasing and may affect up to 15-20 % of infants. The alarming rate of increase calls for a public health approach in the prevention and treatment of food allergy in children.
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45
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Allen UD, Avitzur Y. Eosinophilic esophagitis after organ transplantation and post-transplant lymphoproliferative disorder: more questions than answers. Pediatr Transplant 2014; 18:665-7. [PMID: 25250970 DOI: 10.1111/petr.12338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Upton D Allen
- Division of Infectious Diseases, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; The Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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46
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Lucendo AJ. Cellular and molecular immunological mechanisms in eosinophilic esophagitis: an updated overview of their clinical implications. Expert Rev Gastroenterol Hepatol 2014; 8:669-85. [PMID: 24742298 DOI: 10.1586/17474124.2014.909727] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) is a pathophysiologically complex disorder driven by distinct, multiple mechanisms involving a large number of cells, molecules, and genes. Associated with food allergy from its initial descriptions, a key role for the Th2-type cytokines IL-5 and IL-13 in recruiting and activating eosinophils has been described. Epithelial cells have been recognized as major effectors in initiating EoE, both through their recruitment of iNKT cells towards the esophageal epithelium, which constitutes a major cytokine source, and through the release of eotaxin-3 and other chemoattractants. Epithelial and mesenchymal-released TSLP is a key regulator for which a connecting role between the adaptive and innate mucosal-associated immune response has been suggested. Finally, activated eosinophil- and mast cell-derived TGF β1 secretion is crucial in EoE-associated tissue remodeling.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain
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47
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Romano C, Chiaro A, Lucarelli S, Santarelli C, Cucchiara S, Guadagnini T, Miele E, Di Nardo G. Mucosal cytokine profiles in paediatric eosinophilic oesophagitis: a case-control study. Dig Liver Dis 2014; 46:590-5. [PMID: 24704289 DOI: 10.1016/j.dld.2014.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 03/02/2014] [Accepted: 03/10/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis is an inflammatory condition characterized by a dense eosinophilic infiltrate. The migration of eosinophils into the oesophagus is influenced by cytokines such as IL-5, IL-13 and eotaxin-3. The aim of this study was to evaluate changes in the cytokine expression profiles (IL-5, IL-13 and eotaxin-3/CCL26) in children after topical steroid treatment. METHODS a prospective case-control study was performed in 23 paediatric patients (age 5-16 years) with a histological diagnosis of eosinophilic oesophagitis. Histological evaluation and cytokine levels assay (IL-5, IL-13 and eotaxin-3/CCL26) in the proximal and distal oesophagus were performed before, and after 8 weeks of topical budesonide. Data were compared with a matched healthy control group. RESULTS quantitative expression levels of IL-5, IL-13 and eotaxin-3 were significantly higher in the eosinophilic oesophagitis group both compared to healthy subjects (p<0.0001). A significant reduction of the eosinophil infiltrate as well as of IL-5, IL-13 and eotaxin-3 mucosal profiles was observed after steroid treatment both at the proximal and distal oesophagus (p<0.0001). CONCLUSIONS IL-5, IL-13 and eotaxin-3/CCL26 are significantly over-expressed in the oesophageal epithelium of children with eosinophilic oesophagitis. Topical steroid treatment (inhaled and swallowed budesonide) can induce clinical response with partial mucosal remission.
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Affiliation(s)
- Claudio Romano
- Department of Pediatrics, Paediatric Endoscopy Unit, University of Messina, Italy
| | - Andrea Chiaro
- Department of Pediatrics, Paediatric Endoscopy Unit, University of Messina, Italy
| | - Sandra Lucarelli
- Department of Pediatrics, Paediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Italy
| | - Cinzia Santarelli
- Department of Pediatrics, Paediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Italy
| | - Salvatore Cucchiara
- Department of Pediatrics, Paediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Italy
| | | | - Erasmo Miele
- Department of Pediatrics, University Federico II, Naples, Italy
| | - Giovanni Di Nardo
- Department of Pediatrics, Paediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Italy.
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48
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Zaidi AK, Mussarat A, Mishra A. Diagnostic and therapeutic strategies for eosinophilic esophagitis. ACTA ACUST UNITED AC 2014; 11:351-367. [PMID: 25400904 DOI: 10.2217/cpr.14.31] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis (EoE) is a recently recognized allergic disorder, characterized by eosophageal dysfunction, accumulation of ≥15 eosinophils/high-powered field, eosinophil microabssess, basal cell hyperplasia, extracellular eosinophilic granules in the esophageal epithelial mucosal biopsy and a lack of response to a 8-week proton pump inhibitor treatment. Despite the increased incidences and considerable progress made in understanding EoE pathogenesis, there are limited diagnostic and therapeutic options available for EoE. Currently, the only criterion for diagnosing EoE is repetitive esophageal endoscopic biopsies and histopathological evaluation. Antigen elimination or corticosteroid therapies are effective therapies for EoE but are expensive and have limitations, if continued in the long term. Hence, there is a great necessity for novel noninvasive diagnostic biomarkers that can easily diagnose EoE and assess effectiveness of therapy. Herein, we have provided an update on key molecules involved in the disease initiation, and progression and proposed novel noninvasive diagnostic molecules and strategies for EoE therapy.
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Affiliation(s)
- Asifa K Zaidi
- Department of Medicine, Section of Pulmonary Diseases Tulane Eosinophilic Disorder Center, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Ahad Mussarat
- Department of Medicine, Section of Pulmonary Diseases Tulane Eosinophilic Disorder Center, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
| | - Anil Mishra
- Department of Medicine, Section of Pulmonary Diseases Tulane Eosinophilic Disorder Center, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA
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49
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Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus associated with dysphagia in adults and refractory reflux syndromes in children. METHODS Immunological and genetic approaches have been used to better understand the pathophysiology of the underlying inflammation. RESULTS AND CONCLUSIONS Evidence has accumulated that EoE represents a T-helper (Th) 2-type inflammatory disease, in which allergens play a role in triggering the disease. The majority of the patients suffer from concurrent allergic rhinitis, asthma, and eczema, and have a history of atopy. The chronic inflammatory response in EoE is associated with tissue damage and remodeling, both of which lead to esophageal dysfunction and bolus impaction. The new insights into the pathophysiology have resulted in the development of the first pharmacological therapies of EoE.
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Affiliation(s)
- Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland
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50
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Lucendo AJ, Molina-Infante J. Emerging therapeutic strategies for eosinophilic esophagitis. ACTA ACUST UNITED AC 2014; 12:1-17. [PMID: 24370990 DOI: 10.1007/s11938-013-0001-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Eosinophilic esophagitis (EoE) is recognized as an increasingly common cause of chronic and recurrent esophageal symptoms that significantly impact quality of life and may occasionally result in severe complications in both pediatric and adult patients. The disease is triggered and maintained by exposure to food antigens in most patients, with an additional role proposed for airborne allergens. Different diet-based approaches focused on restricting potentially offending foods have proven to be effective long-term therapies for EoE. Dietary therapy is thus an attractive, yet challenging treatment option that should be considered for all pediatric and adult EoE patients. However, limitations related to food restriction, patient willingness to undergo repeated endoscopies and biopsies, and the variable results of allergy testing imply that dietary management is for the most part currently restricted to highly motivated healthcare providers treating highly motivated patients reluctant to utilize drug-based therapy on a chronic basis. Pharmacological therapies for EoE mainly comprise swallowed topical steroids, especially fluticasone propionate and budesonide, which were originally developed to treat bronchial asthma and are now extensively used "off label" in EoE patients. In fact, topical steroids currently constitute the prevailing therapeutic option and will probably continue to do so in the near future; indeed, several randomized clinical trials are currently underway to test these drugs for approval as the first pharmacological agents for EoE patients. Immunomodulators and several anti-allergic agents must be further assessed as therapeutic alternatives for refractory cases or patients with complications. Endoscopic dilation represents the third pillar in the therapeutic management of EoE patients, since they frequently present reductions in the esophageal caliber as a result of collagen deposition and a progressive fibrous remodeling process promoted by chronic eosinophilic infiltration. Dilation provides at least temporary symptom relief with similar complication rates to esophageal strictures from a different origin. However, although repeated endoscopic dilation has sometimes been used as the sole therapy for EoE, it best constitutes an adjuvant therapy along with dietary or pharmacological-based interventions, especially since dilation has no effect on the underlying esophageal inflammation. Current therapeutic management of EoE varies widely, with physician experience being a major explanatory factor. New evidence from ongoing research on EoE should thus seek to define a common treatment algorithm to optimize EoE patient management.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos, s/n, 13700, Tomelloso, Ciudad Real, Spain,
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