EOSINOPHILIC ESOPHAGITIS TRIGGERED EXCLUSIVELY BY BIRCH AND MUGWORT CROSS-REACTIVE FOODS

Abstract

Introduction Eosinophilic esophagitis (EoE) is characterized by non-IgE hypersensitivity to dietary antigens. Empiric six food elimination diet (SFED: milk, wheat, egg, soy, nuts, and seafood avoidance) leads to 50-74% remission, whereas elemental diet leads to >90% remission, suggesting additional dietary triggers in select patients. Exacerbation during pollen seasons has been demonstrated in a subset of EoE patients. However, a role of pollen cross-reactive foods in triggering EoE is not well established. Case Description We report a 32-year-old female with EoE who had disease remission on targeted elimination diet with birch/mugwort pollen cross-reactive foods alone. At age 22, the diagnosis of EoE was established by suggestive symptoms (dysphagia, epigastric/substernal chest pain) and esophageal biopsies demonstrating >40 eosinophils/high power field (hpf) after 8 weeks of proton pump inhibitor therapy. Empiric SFED did not lead to histological remission (>60 eosinophils/hpf). The patient reported worse EoE symptoms during tree pollen seasons and after ingesting raw birch and mugwort pollen-related foods, but denied oral allergy symptoms. Repeat skin prick tests on two occasions were negative to implicated pollens (wheal/flare (mm) to birch mix: 0/0, mugwort: 0/0). A steroid-sparing, targeted elimination diet of birch/mugwort pollen-related foods alone led to clinical and histological remission, with rare esophageal eosinophils (0-1 eosinophils/hpf). Discussion Pollen cross-reactive foods should be considered as targets for elimination diet therapy in the context of suggestive clinical history. In contrast to a prior report, assessment of pollen IgE-sensitization is not a reliable tool to guide clinical evaluation, consistent with EoE as a non-IgE mediated food hypersensitivity.