S3555 A Case Report: Eosinophilic Esophagitis After an Allegra D Bolus
Justin ChuangKhushbu PatelNaveena LukeJordan BurlenMuhammad AzizSami GhazalehAzizullah BeranAli NawrasAmna IqbalWasef SayehNithin KesireddyDipen PatelSehrish Malik
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Introduction: Eosinophilic esophagitis (EoE) is an immune mediated disorder that may be related to exposure to additive chemicals in crops, air pollutants, or supplements found within livestock. Co-occurring allergic or atopic diseases including atopic dermatitis, food allergies, and asthma are also commonly seen in 70% of cases and help guide diagnosis. Diagnosis of EoE requires eosinophilic infiltration greater than 15 eosinophils per high power field with endoscopic evidence of abnormal esophageal changes. Here, we discuss a rare presentation of food bolus impaction secondary to EoE after ingestion of a nasal decongestant and antihistamine pill that has previously never been described in the literature. Case Description/Methods: A 22-year-old- male with no significant past medical history presented to the emergency department (ED) with a chief complaint of a sudden onset respiratory distress, regurgitation of clear oral secretions, and globus sensation post ingestion of a fexofenadine-pseudoephedrine tablet. Prior to intake of the capsule, the patient was consuming liquids and solids appropriately. The patient was afebrile, hypertensive at 172/114, found to have a normal heart rate of 88 bpm, and respiration rate of 18 breaths per minute. A esophagogastroduodenoscopy (EGD) was performed and revealed a fexofenadine-pseudoephedrine capsule at 23 cm from the incisors along with a superficial ulceration at the corresponding level in the esophagus (Fig. 1A). The foreign body was successfully removed using raptor forceps (Fig. 1B). Further visualization demonstrated trachealization of the esophagus and furrowing and severe narrowing (< 10mm) which raised suspicion for eosinophilic esophagitis (Fig. 1C). Proximal biopsy indicated 16 intraepithelial eosinophils per high-power field within the squamous epithelium likely compatible with eosinophilic esophagitis. The patient tolerated the procedure well and was discharged on a 8 week course of proton pump inhibitors. Discussion: Eosinophilic esophagitis is defined as an immune-mediated esophageal disease characterized histologically by eosinophil-predominant inflammation. Our patient was reported to have up to 30 eosinophil per HPF from the proximal esophageal biopsy which satisfies the requirements for an EoE diagnosis. Based on current literature review, there have been no other reported cases of symptomatic food bolus impaction secondary to eosinophilic esophagitis after ingestion of antihistamines.Figure 1.: EGD results; A: Exofenadine-pseudoephedrine capsule at 23 cm from the incisors along with a superficial ulceration at the corresponding level in the esophagus. B: Foreign body was successfully removed using raptor forceps. C: Trachealization of the esophagus and furrowing with severe narrowing (< 10mm)Keywords:
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Background Esophageal linear furrows, corrugated rings, and/or white exudates are often seen in patients with eosinophilic esophagitis ( EoE ); however, whether these are specific to EoE remains unclear. Endoscopic surveillance of these features was conducted to determine whether these represent esophageal eosinophilia, which is essential for the diagnosis of EoE . Patients and Methods Two thousand seven hundred and sixty‐three patients were enrolled consecutively. Target biopsy was carried out when the above features were seen. Histological eosinophilia was defined as 24 or more eosinophils per high‐power field ( HPF ). Associations between features and eosinophilia were analyzed statistically. Results Two thousand five hundred and forty‐five patients completed the study. Linear furrows, corrugated rings and white exudates were seen in 24, 15 and 45 patients, respectively. These findings somewhat overlapped. Among 58 biopsied patients withany of the above features, these features represented eosinophilia in 14% (3/21), 23% (3/13), and 5% (2/43), respectively. None of the 199 patients who received biopsy for other features had eosinophilia. Two of five eosinophilia patients were diagnosed with EoE . Multiple comparisons revealed that eosinophil counts in linear furrows and corrugated rings but not white exudates were significantly greater than those in other features (12, 9, 1, and <1 eosinophils/ HPF on average, respectively). Conclusions An endoscopic feature suggesting EoE does not always represent esophageal eosinophilia and is non‐specific for EoE , although it reminds endoscopists of the presence of EoE . The diagnostic utility of linear furrows or corrugated rings for esophageal eosinophilia is superior to that of white exudates.
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Introduction: Eosinophil-derived neurotoxin (EDN) is a viable marker of eosinophilic esophagitis (EoE) disease activity. We studied the utility of measuring EDN from esophageal epithelial brushings for diagnosing EoE, focusing on 2 scenarios: 1) cases of exclusive distal eosinophilia and 2) cases of discrepancy between endoscopy and histology. Methods: Records of patients who underwent esophagogastroduodenoscopy (EGD) with EDN measured via esophageal brushings at Orlando Health Arnold Palmer Hospital for Children in Orlando, Florida from January 2014 to October 2018 were retrospectively reviewed. Demographics, clinical, endoscopic, and histologic data were collected. Patients were divided into 2 groups (EoE and controls). EGDs done on EoE patients were further categorized as active or inactive EoE. EGD results were also divided into 4 additional groups based on the distribution of esophageal eosinophilia (PEC ≥15/hpf): >1 level of the esophagus, middle or proximal only, distal only, and no eosinophilia. Results: We reviewed 231 patient records (66.7% male, mean age 10.3 years, range 1-22 years). EDN values correlated with endoscopic reference score (EREFS) and peak eosinophil count (PEC) (Spearman’s rho = 0.756 (P < 0.001) and 0.824 (P < 0.001) respectively). Average PEC, EREFS, and EDN concentrations were higher in patients with active EoE than in controls or patients with inactive disease. When grouping patients based on esophageal eosinophilia distribution, EDN mirrored PEC and EREFS. Patients with exclusive distal eosinophilia had lower EDN concentrations than those with eosinophilia in >1 level of the esophagus (23.8 ±46.1 mcg/ml vs 171.3± 205.8 mcg/ml respectively, P < 0.001). EDN values were more consistent with EREFS in cases of discrepancies between endoscopic findings and pathology (P < 0.001) (Figure 1, Table 1). Conclusion: EDN measured in esophageal brushing samples reflects disease activity objectively and accurately. It also offers significant value in cases of exclusive distal esophageal eosinophilia and when discrepancies exist between endoscopy and histology.Figure 1.: (A) EDN levels based on PEC and EREFS. (B) EREFS based on PEC and EDN (*P<0.001). EDN: eosinophil-derived neurotoxin. EREFS: Endoscopic Reference Score. PEC: peak eosinophilic count. Table 1. - Predictive Values of EDN in EREFS and PEC EDN SN SP PPV NPV AUC Predicting EREFS score ≥1 68.8% 97.0% 96.4% 72.3% 0.870* Predicting EREFS score ≥2 81.9% 95.1% 92.9% 87.0% 0.925* Predicting EREFS score ≥3 88.6% 89.7% 83.0% 93.2% 0.932* Predicting PEC ≥15 in only the distal esophagus 46.2% 62.0% 10.7% 92.1% 0.934* Predicting PEC ≥15 in ≥1 esophageal level 84.4% 94.6% 92.0% 89.3% 0.954* Predicting PEC ≥15 in ≥1 esophageal level excluding distal 94.7% 88.7% 80.4% 97.2% 0.962* Predicting PEC ≥15 in >1 esophageal level 95.5% 86.5% 75.9% 97.7% 0.962* EDN: eosinophil-derived neurotoxin. EREFS: Endoscopic Reference Score. PEC: peak eosinophilic count. SN: sensitivity. SP: specificity. PPV: positive predictive value. NP: negative predictive value. AUC: area under the curve. *P<0.0001.
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Eosinophilic esophagitis (EoE) and gastroesophageal reflux disease are among the major causes of isolated esophageal eosinophilia. Isolated esophageal eosinophilia meeting criteria for EoE may respond to proton pump inhibitor (PPI) treatment. This entity is termed proton pumps inhibitor responsive esophageal eosinophilia (PPI-REE). Gastro-esophageal reflux is thought to comprise a subgroup of patients with PPI-REE. According to the latest guidelines, PPI responsiveness distinguishes people with PPI-REE from patients having EoE (non-responders). In this report, two unusual cases with findings belonging to both EoE and PPI-REE are discussed with known and unknown facts.
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We thank Dr Molina-Infante and colleagues for their interest in our paper.1 We agree with their assessment of the importance of a proton pump inhibitor (PPI) trial in patients with suspected eosinophilic oesophagitis (EoE).2 As our study and the study by Dellon et al. demonstrated,3 PPI-responsive oesophageal eosinophilia (PPI-REE) and EoE have no distinguishing clinical, endoscopic or histological features. While oesophageal eosinophilia responding to PPI therapy was initially believed to be a manifestation of gastro-oesophageal reflux disease (GERD), emerging data support that in many cases, PPI-REE closely resembles EoE.4, 5 Furthermore, many PPI-REE patients do not have classic symptoms or endoscopic findings of GERD and often have a negative 24-hour pH study.1, 6 As Dr Molina-Infante and colleagues mention, both in vivo and in vitro studies now exist which mechanistically explain PPI response in EoE phenotype patients.7, 8 The question remains, however, as to why a subset of patients with oesophageal eosinophilia respond to PPI while others do not. Further studies are needed to give insight into the pathogenesis of PPI-REE and its relationship with EoE. The author's declarations of personal and financial interests are unchanged from those in the original article.1
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Purpose: Eosinophilic Esophagitis (EE) has traditionally been defined by the presence of greater than 20 eosinophils (eos) per high powered field (HPF) on esophageal biopsy. The clinical significance of 20 eos/HPF or fewer is unknown. We hypothesized that EE is a spectrum and lower eosinophil counts reflect similar disease. Methods: 121 adult patients without a previous diagnosis of EE with esophageal biopsies containing 1 to 20 eos/HPF were identified by retrospective review of a database of patients with esophageal eosinophils on biopsy at a tertiary care center between 2002 and 2006. Phone interviews were conducted to ascertain long term symptom control. Results: Patients with 1–5, 6–12, and 13–20 eos/HPF on esophageal biopsy had similar clinical presentations and endoscopic findings (table). There was no statistical difference among sex, race, and age in patients with 13 to 20 eos/HPF compared to those with 1 to 12 eos/HPF. Over 1/3 of patients that had repeat endoscopy were diagnosed with EE (>20 eos/HPF). Phone interviews conducted with 16 patients (5 with 1–12 eos/HPF) who received swallowed topical corticosteroids found symptomatic improvement in all 16 patients following six weeks of treatment. Conclusion: Patients with a clinical presentation consistent with EE and indeterminate esophageal eosinophils on biopsy should be treated for EE. The number of eosinophils per HPF on biopsy appears to be less relevant than the clinical presentation. Moreover, the current diagnostic value of greater than 20 eos/HPF should be reevaluated.Table: Clinical Features of Patients with 1–20 EOS per HPF
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Objective According to consensus guidelines, eosinophilic esophagitis (EoE) is defined as a clinicopathological entity whose symptoms and histology must always be considered together. However, endoscopic findings typical of EoE are often seen in asymptomatic esophageal eosinophilia (aEE). We aimed to clarify the clinicopathological features of aEE. Methods We retrospectively compared cases of aEE and those of symptomatic EoE. Materials We reviewed 146 patients who underwent upper gastrointestinal endoscopy and were confirmed histopathologically to have esophageal eosinophil infiltration of at least 15 eosinophils per high-power field. They were divided into the aEE group (n=75) and the EoE group (n=71). Patients' clinicopathological findings were then collected and examined. Results The EoE group experienced dysphagia (47.9%), heartburn (40.8%), food impaction (40.8%), chest pain (16.9%), and other symptoms (8.5%). There was no significant difference between the two groups with regard to age, sex, current smoking status, or alcohol consumption. The aEE group had a significantly higher body mass index (p<0.01) and significantly lower frequency of concurrent allergic diseases (p<0.01) than the EoE group. No significant differences were found between the two groups with regard to the mean peripheral blood eosinophil count, non-specific immunoglobulin E concentration, peak eosinophil infiltration in the biopsy specimens, EoE histology scoring system, phenotype and location of typical endoscopic findings of EoE, or thickness of the esophagus wall or the mucosal and submucosal layer as measured by endoscopic ultrasonography. Two patients in the aEE group who were followed up without treatment subsequently developed esophageal symptoms. Conclusion aEE and EoE may have the same clinicopathological features.
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Esophageal eosinophilia and eosinophilic esophagitis (EoE) are increasingly recognized and prevalent conditions, which now represent common clinical problems encountered by gastroenterologists, pathologists, and allergists. The study of EoE has become a dynamic field with an evolving understanding of the pathogenesis, diagnosis, and treatment. Although there are limited data supporting management decisions, clinical parameters are needed to guide the care of patients with eosinophilic-esophageal disorders. In this evidence-based review, recommendations developed by adult and pediatric gastroenterologists are provided for the evaluation and management of these patients. New terminology is emphasized, particularly the concepts of esophageal eosinophilia and proton-pump inhibitor-responsive esophageal eosinophilia (PPI-REE) as entities distinct from EoE.
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