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- Esophagitis -
10/7/05 re: Treatment of eosinophilic esophagitis In reviewing the responses regarding management of eosinophilic esophagitis fluticasone is mentioned as a treatment option especially in those patients not improving with strict dietary avoidance of allergens - what isn't mentioned is the length of treatment often recommended by the specialist especially the Cincinnati clinic. I presently have a 10 year old patient with endoscopic confirmed eosinphilic esophagitis (moderate to severe) with well documented food allergies and he has been on the flovent (50 micrograms) twice daily for 6 weeks, he is showing improvement and parents would like to wean therapy. I am questioning if 6 weeks is long enough or should we continue longer from the experience of others with this thank you for any assistance you could provide. I referred your questions to Dr. Marc Rothenberg, the senior investigator in the group in Cincinnati to which I think you were referring in your message. Dr. Rothenberg is a close colleague (we co-edit a section of the Journal of Allergy and Clinical Immunology) and he responded promptly. His comments are enclosed below. I believe that he recommends that you should try higher doses of oral fluticasone, taper the dosage when there is impressive improvement but continue that maintenance dose for considerably longer than the current duration. The parents can be encouraged to do this because of concerns about relapses if the dose is withdrawn at this stage of the disease.
Dr. Rothenberg's comments:
Burt-hope you are well. We recommend 440 mcg BID swallowed and this has to be maintained long term (possibly lower dose after remission) but disease will return if therapy is withdrawn.
6/28/04 re: Approach to child with eosinophilic esophagitis One of the RN's in my unit has a 5 year old boy with Eosinophilic Esophagitis. The nurse has contacted Children's Hospital Medical Center in Cincinnati and inquired what she could give the child to eat because everything he eats causes his airway to obstruct due to his allergic reaction. Nobody has been able to give her any information and she has not been able to find anyone who has a child with this disease that is this severe to give her any support. The child is allergic to beef, chicken, chocolate, corn, carrots, rice and beans and fruit of any kind that I know of. Basically the only thing he is really able to eat is wheat and he drinks a type of liquid gluten drink. He is not growing properly because he is not eating properly. It is causing the child severe self-image problems and certainly it is very difficult to be hungry all the time and not be able to eat anything that tastes good to take care of the hunger. Eating habits of a 5 year old are bad enough but with this poor child it is unbearable. Do you have any resources available for them that you could send me? Any resource at all would be helpful at this point. The child has been treated since birth and his allergies are only getting worse instead of better. I assume that the diagnosis of eosinophilic esophagitis (EE) has been confirmed by biopsy in the child you described. It is true that food allergies are present in a sizable percentage of children with EE and avoidance of proven food offenders is generally recommended. I am surprised to see your comments that the people contacted at the Children's' Hospital Medical Center of Cincinnati (CHMCC) could not advise your colleague since Dr. Rothenberg's unit in the CHMCC is one of the leading investigative groups in EE in the world (see enclosed article.) They have a website which contains helpful information. They also are evaluating certain medication treatment protocols in EE (see enclosed response from Dr. Rothenberg to a previous Ask the Expert question about EE sent to this AADMC website). Therefore, if the child you described has not been evaluated by that group, I would strongly recommend this approach.
Pediatric Health News Releases December 27, 2000 - Cincinnati Children's Researcher Uncovers Allergy Reflux Link -- Study Has Significant Treatment Implications
CINCINNATI -- A new Children's Hospital Medical Center of Cincinnati discovery may have significant implications for children with eosinophilic esophagitis, a fast-growing new disease whose symptoms mimic gastroesophageal reflux, and for adults with reflux who are not being helped by currently available medications. In a study published in the January issue of The Journal of Clinical Investigation, Marc E. Rothenberg, M.D., Ph.D., has established a link between reflux and allergy -- not only food allergies but also environmental allergens such as pollens and molds. Dr. Rothenberg, the study's senior author, and his colleague Anil Mishra, Ph.D., have developed the first experimental system, a mouse model, for eosinophilic esophagitis -- a disease whose numbers have exploded in recent years. "We're saying that what a person breathes in can actually affect the gastrointestinal system," says Dr. Rothenberg, who directs the section of allergy and clinical immunology in Cincinnati Children's Division of Pulmonary Medicine, Allergy and Clinical Immunology. "There is a direct link between exposure to allergens that go to the lung -- aeroallergens -- and development of esophageal inflammation." Moreover, Dr. Rothenberg has discovered that this pathway is mediated by a molecule called interleukin-5. When Dr. Rothenberg's research group gave mice an allergen that induced asthma, all the mice developed esophagitis. But none of the mice deficient in IL-5 who were given the allergen developed esophagitis. "They were completely protected," says Dr. Mishra, Ph.D., a research associate in Dr. Rothenberg's lab and the study's lead author. "Two major pharmaceutical companies have an antibody in human trials that blocks IL-5," adds Dr. Rothenberg. "These drugs are being tried for asthma, but based on our findings I'd like to see IL-5 blockers tried in patients with eosinophilic esophagitis." Children with eosinophilic esophagitis often have abdominal pain, difficulty swallowing, vomiting, failure to thrive and weight loss. Just a few years ago, incidents of the disease were rare. Now, Dr. Rothenberg and his colleagues at Cincinnati Children's food allergy clinic treat about 60 cases each year. Physicians throughout the United States also report an explosion in the number of cases. Adults with reflux have some similar symptoms. While many are helped by currently available medications, there is a significant subset that, like children with esophagitis, is not helped. Dr. Rothenberg believes that "a significant number of those may have an allergen-driven process; they have a different form of reflux that we're calling eosinophilic esophagitis." Dr. Rothenberg derives the name from the fact that when patients came to Cincinnati Children's Medical Center with esophagitis, biopsies showed a large infiltration of eosinophils, a type of white blood cell not normally seen in the esophagus, into the gastrointestinal tract. Eosinophils in tissue are also a hallmark feature of an allergic response. The associations between eosinophils and esophagitis, and eosinophils and reflux have been previously reported, but Dr. Rothenberg noticed that many children in the allergy clinic had gastrointestinal complaints. "When you skin test patients with eosinophilic esophagitis, 80 percent have allergies," he says, "not only food allergies but also environmental aeroallergens. This suggested that allergies may be a cause for the esophagitis. One of the things that struck me," adds Dr. Rothenberg "is that we know that people who develop reflux often have asthma. There seems to be some link between the two. In fact, when those with asthma are treated for reflux they sometimes get better. Based on this clinical observation, and with the hunch that there was likely to be an association between the development of allergy and esophagitis, our research group subsequently developed the mouse model to prove it." The results, which shed new light on a possible cause of esophagitis, suggest that therapy should be directed at controlling allergies and preventing exposure to environmental allergens.
Dr. Rothenberg's response to a previous Ask The Expert question:
With regard to eosinophilic esophagitis, the diagnosis is made based on the number of eosinophils and the degree of epithelial hyperplasia (all markedly higher than in just Gastroesophageal Reflux alone). The presence of positive skin tests indicates that he has the allergic variant. We find that a strict dietary avoidance is very helpful. It has to be strict and comprehensive - all foods that are positive on an extended food prick testing panel. We also recommend strict environmental control since aeroallergens have also been implicated in the disease pathogenesis. We generally re-scope after three months of this intervention. Refractory patients are then treated with "inhaled" fluticasone - don't use the spacer and have them swallow the drug. Some patients require elemental diets, if they don't respond to the other treatments.
5/14/01 re: Management of eosinophilic gastroenteritis A seven year old boy was hospitalized because of severe esophagitis. Cultures of esophageal ulcerations were positive for herpes simplex virus. However, the biopsies reveal marked intramucosal eosinophilia.
The boy has a history of intermittent asthma and recurring sinus infections. Quantitative immunoglobulins were normal. He had no history of allergy to specific foods, but he was intolerant of milk formula during infancy (he spit up a lot).
Skin tests showed positive reactions to many inhalant allergens (cat, dog, mites, many pollens) and foods (milk, peanut 4+, pea 3+, oat). For three months, he avoided milk, peanut, and legumes. There was no improvement in his esophageal eosinophilia.
Should his diet continue to be restricted in any way? Why or why not?
A lot of children have positive skin tests for foods, but no "immediate" reaction to DBPCFC. Are we missing something by not looking for the esophageal or gastric eosinophilia?
I have had no experience with the situation you describe, since I have not treated small children for many years. Therefore, I consulted Dr. Marc Rothenberg of the Children's Hospital Medical Center in Cincinnati. Dr. Rothenberg is an expert investigator of eosinophilic gastroenteritis. His reply is enclosed below.
The patients sounds like he has classic eosinophilic esophagitis except for the HSV infection. The latter finding is not associated with eosinophilic esophagitis, so it may be a coincidental finding. With regard to eosinophilic esophagitis, the diagnosis is made based on the number of eosinophils and the degree of epithelial hyperplasia (all markedly higher than in just GASTROESOPHAGEAL REFLUX alone). The presence of positive skin tests indicates that he has the allergic variant. We find that a strict dietary avoidance is very helpful. It has to be strict and comprehensive - all foods that are positive on an extended food prick testing panel. We also recommend strict environmental control since aeroallergens have also been implicated in the disease pathogenesis. We generally re-scope after three months of this intervention. Refractory patients are then treated with "inhaled" fluticasone - don't use the spacer and have them swallow the drug. Some patients require elemental diets, if they don't respond to the other treatments.
