A Complication of Eosinophilic Esophagitis from Sublingual Immunotherapy
Saturday, March 5, 2016
South Exhibit Hall H (Convention Center)
Charmi Patel, Prem K. Menon, MD FAAAAI
Rationale: Sublingual Immunotherapy (SLIT) is an emerging treatment for sensitization to aeroallergens due to convenience and lesser risk of anaphylaxis. Eosinophilic Esophagitis (EoE) is described with food desensitization protocols in milk, egg and peanut, but only one case report associates EoE triggered by SLIT for pollen.

Methods: Esophagogastroduodenoscopy was performed with biopsies.

Results: 11-year-old male with history of allergic rhinitis due to sensitization to grass, trees and cats treated with grass SLIT for one-year presented with three-month history of burning epigastric pain. He has associated odynophagia and dysphagia without food triggers. He tried one month of esmoprazole twice daily and antacids without relief. An esophagogastroduodenoscopy revealing furrowing of the esophagus. Biopsies showed up to 35 eosinophils per high-powered field and superficial layering of eosinophils consistent with EoE. He was taken off SLIT with subsequent resolution of symptoms.

Conclusions: In the literature, oral immunotherapy for milk, peanut and egg desensitization is described to trigger EoE. There is only one case report of EoE with SLIT drops when using birch, hazelnut and alder extract and no cases are reported as a complication of purely grass SLIT tablets. We hypothesize that consistent exposure of an allergen that is partly tolerated may trigger EoE, but the mechanism is unknown. As patients elect oral options over invasive subcutaneous immunotherapy, EoE should be considered as an adverse effect and be studied further in these circumstances. Treatment is removing the offending agent and consider swallowed steroid during the initial symptoms.