Cough, asthma, EoE and biologic therapy
Question:
5/31/2018
63 year-old female nurse with allergic rhinitis, asthma with chronic cough approximately 5 years ago unresolved with Dulera, Spiriva, Singulair. In the past cough worsened with eating and also occurs upon awakening or with sinusitis. Pt had trial of Prilosec with no change for over a year. She is on allergen immunotherapy for severe seasonal allergic rhinitis to tree pollens. Seasonal allergic rhinitis to grass and weed pollens. Perennial allergic rhinitis to dust mites, cat saliva, dog dander and mold spores. She requires oral steroids 2-3 times per year for 'asthma', and no change with xolair for a year, now on Nucala since 6/2016.
2015 Labs: tot IgE 59, Eos 5.7%; Eos # = 387.
2018: IgG 682 slightly low; zero Eos; ANCA neg, total igE 86 wnl; Asp fumigatus 0.5 c 2.
2018 CT chest - No bronchiectasis; mild air trapping throughout both lungs; no infiltrates. Normal spirometries, even when symptomatic, therefore we follow peak flows.
2018: FVC= 109% predicted. FEV1= 119% predicted, FEV1/FVC= 0.84, PEFR= 98% predicted, FEF25-75%= 163%.
She had refused upper endoscopy, as did a GI doctor over the years. However recently she had an episode of food impaction resulting in EGD. EGD findings of moderate severe acute gastritis in antrum. Impacted food. Stricture/ring present in GE junction; dilation performed. Biopsy of Mid esophagus: mildly reactive squamous mucosa with patchy intraepithelium eosinophila 10/HPF. Pt started on Nexium. GI asked her to follow up with her allergist.
Questions:
1. Even though she does not fulfill biopsy criteria for EoE of 25/HPF, would you still consider EoE diagnosis since Eos are in mid esophagus location, although stricture present in GE junction location? If so, then would you do prick testing for an EoE food panel to see if food allergies are the cause of her eosinophils?
2. Do you think her asthma diagnosis is in question, consider her normal spirometries, lack of reduction of systemic steroids on Xolair or Nucala, although she responds to albuterol and Spiriva? Could GERD be causing her 'asthma' even though she responds to bronchodilators and steroids, but that should have made GERD worse? Her lower respiratory symptoms are mainly with infections and she has a daily cough. She requests to increase her ICS seasonally even with normal spirometries.
Answer:
I asked both Dr. Patricia Fulkerson, an eosinophil expert, and Dr. Sally Wenzel, an asthma expert, to provide input.
Dr. Fulkerson's reply is as follows: "If she was on Nucala at the time of her EGD, then she may be partially treated and may meet histologic criteria off therapy, so the diagnosis of EoE will be difficult to confirm at this time. A follow-up EGD on Nexium will be helpful to see if the eosinophil counts decrease further. With regard to skin testing, it is generally not possible to define the triggers for esophageal eosinophilia by skin prick allergy testing or by allergen-specific IgE levels. Testing that is dependent upon IgE-mediated mechanisms fails to correctly identify triggers as EoE is not an IgE-mediated process (Simon D, et al, Allergy 2016; PMID: 26799684). Skin patch testing has fallen out of favor as a means to identify possible dietary triggers for a number of reasons. For better or worse, empiric dietary elimination and reintroduction has been the most effective means to precisely identify causative foods (triggers) for EoE."
Dr. Wenzel's reply was as follows: "I think the diagnosis [of asthma] is very much in question. I would suggest that good flow volume loops are obtained, as well as methacholine challenge, with a laryngoscopy. Persistently normal spirometry in presence of symptoms almost never is asthma. I would think that GERD induced VCD is the most likely diagnosis, with a 2ndary impact on sinusitis, which probably further worsens the situation. If a FeNO can be obtained off of systemic CSs that can be helpful too. I do tend to repeat eos often, but if on oral steroids and nucala likely will be zero on a CBC but not necessarily zero in tissue. However, if the esophageal bx was done on nucala, then the eos MIGHT be decreased there too, but she still could have EoE. "
I trust that you will find this input helpful.
Regards,
Daniel Jackson, MD FAAAAI