Does Aeroallergen Sensitization Cause or Contribute to Eosinophilic Esophagitis?

Eosinophilic esophagitis is an atopic disease defined clinically by esophageal symptoms in combination with a dense esophageal eosinophilia. EoE is triggered and maintained by exposure to certain foods and it is known that dietary modification controls symptoms and achieves disease remission. Recently, aeroallergens have been implicated in the pathogenesis of EoE. To examine the role of aeroallergens in EoE, we reviewed the published literature. Sensitization and production of IgE antibodies to foods and aeroallergens in subjects with EoE has been demonstrated. However, the evidence suggests only a minor role for IgE-mediated immune reactions in EoE. There is some evidence to support an association of EoE diagnosis and flares with environmental allergen exposure, and animal studies support the notion that EoE may be induced by exposure to inhalant allergens. Some studies show that newly diagnosed cases of EoE follow a seasonal pollen distribution (summer and spring), but the weight of evidence does not support the seasonal occurrence of diagnosis or worsening of symptoms. Overall, we conclude that the current evidence does not support causality in inhalant allergen exposure and the genesis nor exacerbations of EoE in humans, although there is a possibility that inhalant allergen sensitization could play a modifying role in EoE in the context of cross-reacting food allergens.

Feasibility of spirometry testing in preschool children.

RATIONALE: The primary purpose of this study was to evaluate the feasibility of obtaining acceptable and reproducible spirometry data in preschool aged children (3-5 years) by technicians without prior experience with spirometry. METHODS: Two technicians were trained to perform spirometry testing (ndd Easy on-PC) and to administer standardized questionnaires. Preschool aged children were enrolled from two Head Start centers and a local primary care clinic. Subjects were trained in proper spirometry technique and tested until at least two acceptable efforts were obtained or the subject no longer produced acceptable efforts. RESULTS: 200 subjects were enrolled: mean age 4.0 years (± 0.7 SD); age distribution: 51 (25.5%) 3 years old, 103 (51.5%) 4 years old, and 46 (23%) 5 years old. Fifty-six percent male and 75% Hispanic. One hundred thirty (65%) subjects produced at least one acceptable effort on their first visit: 23 (45%) for 3 years old, 67 (65%) for 4 years old, and 40 (87%) for 5 years old. The number of acceptable efforts correlated with age (r = 0.29, P < 0.001) but not gender. The mean number of acceptable efforts on the first visit was 2.66 (± 2.54 SD; range 0-10). One hundred twenty subjects (60%) had two acceptable efforts; 102 had FEV0.5 within 10% or 0.1 L and 104 had FVC within 10% or 0.1 L of best effort. The Asthma Health Screening Survey (AHSS) was 78% sensitive when compared to a specialist exam and 86% compared to a self-reported prior diagnosis of asthma. CONCLUSIONS: Technicians without prior experience were able to obtain acceptable and reproducible spirometry results from the preschool aged children; the number of acceptable efforts correlated significantly with age.

Effects of a patient's name and image on medical knowledge acquisition.

PURPOSE: To assess whether there are differences in medical students' (MS) knowledge acquisition after being provided a virtual patient (VP) case summary with a patient's name and facial picture included compared to no patient's name or image. METHOD: 76 MS from four clerkship blocks participated. Blocks one and three (Treatment group) were provided case materials containing the patient's name and facial picture while blocks two and four (Control group) were provided similar materials without the patient's name or image. Knowledge acquisition was evaluated with a multiple-choice-question examination (CQA_K). RESULTS: Treatment group CQA_K scores were 64.6% (block one, n = 18) and 76.0% (block three, n = 22). Control group scores were 71.7%, (block two, n = 17) and 68.4% (block four, n = 19). ANOVA F-test among the four block mean scores was not significant; F (3, 72) = 1.68, p = 0.18, η2=0.07. Only 22.2% and 27.3% of the MS from blocks one and three respectively correctly recalled the patient's name while 16.7% and 40.9% recalled the correct final diagnosis of the patient. CONCLUSIONS: These results suggest that including a patient's name and facial picture on reading materials may not improve MS knowledge acquisition. Corroborating studies should be performed before applying these results to the design of instructional materials.

Isolation of Exophiala dermatitidis from pigmented sputum in a cystic fibrosis patient.

A 16-year-old female with cystic fibrosis (CF) presented with an acute respiratory exacerbation during which black flecks were observed in the spontaneously expectorated sputum. The production of this pigmented sputum was subsequently attributed to Exophiala dermatitidis hyphae. Treatment with antibiotics, corticosteroids, and antifungal medications led to an initial resolution of symptoms and clearance of the black pigment from her sputum. However, the patient again presented nine months later with reappearance of the pigmented flecks and concomitant clinical deterioration and was subsequently treated with an extended course of voriconazole. To the authors' knowledge, this is the first case report of fungal colonization by E. dermatitidis presenting as black flecks spontaneously expectorated in CF sputum.

Pediatric patients with eosinophilic esophagitis: an 8-year follow-up.

BACKGROUND: Eosinophilic esophagitis (EE) is a gastrointestinal disorder that is increasingly diagnosed in pediatric patients. OBJECTIVE: We aimed to define, in pediatric patients with EE, their demographic and atopic characteristics, the histopathology of all segments of the gastrointestinal tract, and the effect of therapeutic interventions on the natural history. METHODS: We conducted a retrospective analysis of a database of pediatric patients with EE followed over a period of 8 years. RESULTS: In 89 pediatric patients with EE, male sex (78.6%), white race (94.4%), young age at diagnosis, mean +/- SD, 6.2 +/- 4.8 years, and atopy with sensitization to environmental and food allergens in 79% and 75%, respectively, were prevalent. Patients had EE of the proximal and distal esophagus, and 77% had in addition either mucosal eosinophilia or noneosinophilic histopathology in the stomach, duodenum, and colon. EE was chronic, with a duration of mean +/- SD, 0.91 +/- 0.84 years, until first resolution, and was recurrent; of 66% of the patients who had resolution, 79% later relapsed. CONCLUSION: Eosinophilic esophagitis in the pediatric population is a chronic and relapsing condition, associated with atopy and sometimes with subsequent histopathology in segments of the gastrointestinal tract other than the esophagus. CLINICAL IMPLICATIONS: Physicians evaluating pediatric patients with chronic gastrointestinal symptoms should consider the diagnosis of EE, particularly in young white male patients with atopy. Once diagnosed and treated, the physicians should follow the patients over a period of several years because the course of the disease is protracted, other gastrointestinal segments may be affected, and relapses are common.

Chylothorax in Henoch-Schonlein purpura: a case report and review of the literature.

Henoch-Schonlein purpura (HSP) is the most common acute vasculitis in the pediatric population, with an incidence of 10-14 per 100,000. The classic presentation of this disorder includes erythematous papules followed by palpable purpura in the lower extremities, trunk, and face, arthralgia or arthritis, abdominal pain, gastrointestinal bleeding, and nephritis. While renal abnormalities in HSP are common, the classic pulmonary manifestations, such as hemorrhage and pneumonitis, are thought to be infrequent. Subclinical pulmonary manifestations, including diffusion defects and radiographic anomalies, seem to be quite frequent in patients with HSP but are not commonly reported. Other respiratory manifestations include pleural effusion and chylothorax, but these are rarely mentioned in the literature. Chylothorax was only reported once in an adult patient with HSP in whom the mechanism of formation was demonstrated to be secondary to transdiaphragmatic passage of chylous fluid from the peritoneal cavity. Here we describe an 8-year-old girl with HSP, nephrotic syndrome, and chylothorax, and we report the results of a review of the literature regarding respiratory complications in HSP. The present case is the first pediatric patient reported with HSP and chylothorax. The therapeutic measures utilized were effective in resolving her edema, ascites, and chylothorax, and we advocate the use of these measures as first-line therapy in future patients with similar complications from HSP.

Altered gene expression profiles in nasal respiratory epithelium reflect stable versus acute childhood asthma.

BACKGROUND: Asthma is the most common chronic disease of childhood and has a strong genetic component. OBJECTIVE: To identify gene expression signatures that reflect asthma-related processes and to determine whether these genes were similar or distinct between stable asthma and acute exacerbations in childhood, we profiled gene expression patterns in nasal respiratory epithelial cells. METHODS: Children who had stable asthma (asthma-S; n = 10) and children experiencing an asthma exacerbation (asthma-E; n = 10) were recruited along with nonatopic children without asthma (n = 10). RNA was prepared from nasal respiratory epithelial cells isolated from each child, initially analyzed as pooled samples from the 3 groups, and further validated by using microarrays and RT-PCR with individual patient samples. RESULTS: Distinct gene clusters were identifiable in individual and pooled asthma-S and asthma-E samples. Asthma-E samples demonstrated the strongest and most reproducible signatures, with 314 genes of 34,886 measured as present on the chip demonstrating induction or repression of greater than 2-fold with P < .05 in each of 4 individual samples. Asthma-S-regulated genes encompassed genes that overlapped with those of asthma-E but were fewer (166) and less consistent with respect to their behavior across the asthma-E patient samples. CONCLUSION: Exacerbated asthma status is readily distinguished based on the occurrence of strong gene expression signatures in nasal epithelial samples. Stable asthma status also exhibits differential signatures. The results suggest that there are independent gene expression signatures reflective of cells and genes poised or committed to activation by an asthma attack.

Clinical and immunopathologic effects of swallowed fluticasone for eosinophilic esophagitis.

BACKGROUND & AIMS: Eosinophilic esophagitis (EE) is a recently recognized clinical disorder that is understood poorly. We aimed to determine the efficacy of swallowed fluticasone propionate on the immunopathologic features associated with EE. METHODS: A retrospective analysis was performed on 20 pediatric patients with EE. Inclusion criteria specified a peak eosinophil density of > or =24 cells per 400x field in the esophagus and treatment with swallowed fluticasone between 2 endoscopic assessments. Histologic specimens were examined for eosinophil and CD8(+) lymphocyte infiltration, papillary lengthening, and proliferation of the basal layer as determined by monoclonal anti-Ki-67 (MIB-1) antibody staining. RESULTS: The mean time interval between endoscopic assessments was 4.8 months. The patients were divided equally between allergic and nonallergic groups based on the results of skin-prick testing. All of the nonallergic patients responded to fluticasone propionate. The endoscopic appearance of the mucosa improved and microscopic evaluation showed markedly reduced eosinophil infiltration, reduced basal layer hyperplasia documented by a reduced number of MIB-1(+) cells, and a reduced number of CD8(+) lymphocytes. However, allergic patients were relatively refractory to therapy; 20% had a partial response, whereas 20% had no detectable improvement. Esophageal eosinophil levels before and after therapy in all patients strongly correlated with the level of epithelial cell proliferation as measured by MIB-1 staining. CONCLUSIONS: Collectively, these results suggest that patients treated with swallowed fluticasone have improved endoscopic, histologic, and immunologic parameters associated with EE. However, patients with identifiable allergies who fail dietary elimination may have a blunted response to treatment.

Eosinophil-associated gastrointestinal disorders: a world-wide-web based registry.

A world wide web database was established that tracked features of eosinophil-associated gastrointestinal disorders; 80% had coexisting atopic disease, 62% had food sensitization, and 16% had an immediate family member with a similar disorder. Developmental delay, seizure disorders, and congenital anomalies were seen in a proportion of respondents. The world wide web has proven to be an efficient tool to gather patient information, allowing us to define distinguishing features of various eosinophil-associated gastrointestinal disorders and to establish that these disorders have strong genetic and allergic components.