Allergic components of eosinophilic esophagitis - 04/07/18

Doi : 10.1016/j.jaci.2018.05.001

Jonathan Spergel, MD, PhD ^a, Seema S. Aceves, MD, PhD ^b,^⁎
^a Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, and the Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
^b Departments of Pediatrics and Medicine, Division of Allergy Immunology, University of California, San Diego, Rady Children's Hospital San Diego, La Jolla, Calif

^∗Corresponding author: Seema S. Aceves, MD, PhD, Division of Allergy and Immunology, University of California, San Diego, 9500 Gilman Dr, MC-0760, La Jolla, CA 92093.Division of Allergy and ImmunologyUniversity of California, San Diego9500 Gilman DrMC-0760La JollaCA92093

Abstract

Information for Category 1 CME Credit

Credit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the following instructions.

Method of Physician Participation in Learning Process: The core material for these activities can be read in this issue of the Journal or online at the JACI Web site: www.jacionline.org. The accompanying tests may only be submitted online at www.jacionline.org. Fax or other copies will not be accepted.

Date of Original Release: July 2018. Credit may be obtained for these courses until June 30, 2019.

Overall Purpose/Goal: To provide excellent reviews on key aspects of allergic disease to those who research, treat, or manage allergic disease.

Target Audience: Physicians and researchers within the field of allergic disease.

Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

List of Design Committee Members: Jonathan Spergel, MD, PhD, and Seema S. Aceves, MD, PhD (authors); Zuhair K. Ballas, MD (editor)

Disclosure of Significant Relationships with Relevant Commercial

Companies/Organizations: The authors have declared that they have no relevant conflicts of interest. Z. K. Ballas (editor) disclosed no relevant financial relationships.

Activity Objectives:

1.	To understand the pathogenesis of eosinophilic esophagitis (EoE).
2.	To know the common triggers of EoE.
3.	To become familiar with testing methods and their limitations for identifying triggers in patients with EoE.

Recognition of Commercial Support: This CME activity has not received external commercial support.

List of CME Exam Authors: Sonia Joychan, MD; Fatima Khan, MD; and Warit Jithpratuck, MD (fellows), and Mark Ballow, MD, and Panida Sriaroon, MD (faculty mentors)

Disclosure of Significant Relationships with Relevant Commercial

Companies/Organizations: The exam authors disclosed no relevant financial relationships.

Eosinophilic esophagitis (EoE) is a disorder of increasing prevalence worldwide, causing clinical symptoms of vomiting, failure to thrive, and dysphagia and complications of esophageal remodeling with strictures and food impactions. Molecular profiling demonstrates EoE to be an eosinophil-predominant disorder with a T_H2 cytokine profile reminiscent of other allergic diseases, such as asthma, allergic rhinitis, and atopic dermatitis. Environmental antigens in the form of foods and aeroallergens induce eosinophil, basophil, mast cell, and T-cell infiltration. Pathogenesis depends on local epithelial immune activation with production of thymic stromal lymphopoietin and eotaxin-3. Complications mirror asthmatic airway pathogenesis, with increases in subepithelial collagen deposition, angiogenesis, and smooth muscle hypertrophy. The removal of instigating antigens, especially foods, causes disease resolution in more than 50% of adults and children. The prevalence of concurrent atopic disorders in patients with EoE and the need to control antigen-specific T_H2 inflammation underscore the importance of testing for allergens and treating the entire atopic subject to control the potential interplay between organ-specific allergic responses.

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Key words : Esophagitis, food allergy, allergic rhinitis, antigens, allergy testing

Abbreviations used : EoE, ISAC, PPI, PR-10, SLIT, TSLP

Plan

Food antigens

Testing modalities for EoE-triggering foods

Aeroallergens as antigens in patients with EoE

Oral allergy syndrome in patients with EoE

Potential prognostic features of allergic sensitization

Discussion

J.S. has received funds from the Stuart Starr Endowed Chair and the Children's Hospital Food Allergy Fund. Support was also provided from National Institutes of Health/National Institute of Allergy and Infectious Diseases (NIAID) grants AI 092135 (to S.S.A.) and K24AI135034 (to S.S.A.). Both J.S. and S.S.A. have received funding from the Consortium for Gastrointestinal Eosinophilic Researchers (CEGIR). CEGIR (U54 AI117804) is part of the Rare Diseases Clinical Research Network (RDCRN), an initiative of the Office of Rare Diseases Research (ORDR), National Center for Advancing Translational Sciences (NCATS), and is funded through collaboration between NIAID, National Institute of Diabetes and Digestive and Kidney Diseases, and NCATS.