Eosinophilic Esophagitis Induced By Aeroallergen Sublingual Immunotherapy in an Enteral Feeding Tube Dependent Pediatric Patient
Saturday, March 5, 2016
South Exhibit Hall H (Convention Center)
Cindy S Bauer, MD, Michaela M Tvrdik, Shauna Schroeder, MD
Rationale: Eosinophilic esophagitis (EoE) is an increasingly recognized eosinophilic gastrointestinal disorder triggered by food antigens.  Data suggests that aeroallergens may also play a pathogenic role.  Here we present a 9-year-old male who developed EoE after initiating aeroallergen sublingual immunotherapy (SLIT).

Methods: Esophageal biopsies were performed at Phoenix Children’s Hospital.

Results: A 9-year-old male with history of severe feeding disturbance, G-tube dependency, autism, reflux, asthma, and allergic rhinoconjunctivitis was referred for esophageal eosinophilia.  Initial endoscopic biopsy performed during G-tube placement for oral aversion was normal on proton pump inhibitor (PPI) therapy.  Because of continued feeding refusal, repeat evaluation on elemental formula and PPI was performed and showed marked esophagitis (57 eosinophils/40X HPF in the distal esophagus; June 2013).  In June 2014 on elemental diet, PPI, and non-adherence of swallowed corticosteroids, his eosinophilia persisted (32, 46, and 47 eosinophils/40X HPF in the distal, mid, and proximal esophagus, respectively).  Further history revealed the patient started aeroallergen SLIT in May 2013 (grass, tree, and dust mite).  Both topical corticosteroids and SLIT were discontinued and in June 2015 on elemental diet and PPI, his repeat endoscopy showed resolution of his eosinophilia.

Conclusions: The resolution of esophageal eosinophilia after cessation of aeroallergen SLIT in a patient continued on elemental diet and PPI throughout, strongly implicates aeroallergen SLIT as the trigger. Two previous reports have described EoE in adults receiving aeroallergen SLIT; however, neither had baseline endoscopic biopsy nor elemental diet throughout.  To our knowledge, this is the first pediatric case, raising concern for the safety of pediatric aeroallergen SLIT.