To Test or Not to Test? A Role for Comprehensive Food and Aeroallergen Testing in Adults With Eosinophilic Esophagitis

Abstract

Introduction: Eosinophilic esophagitis (EoE) in adults is an important cause of dysphagia with treatment focused on proton pump inhibitors, topical corticosteroids, and food elimination diets. The role of allergy testing-selective elimination diets that excludes foods based upon skin testing has been questioned with strategies being replaced with increasing use of various modifications of the two, four, and six-food elimination plans. The object of this study was to retrospectively analyze our 10-year approach of comprehensively skin testing of foods and aeroallergens in adults with EoE and directing management based on these results. Methods: A medical records review of food and environmental allergy tests in adults referred for allergy evaluation with EoE between January1, 2006 through 2016. Subjects tested to a panel of 35 foods and 36 aeroallergens. Medical records were also reviewed to capture demographics, endoscopic findings, medication use, and symptoms. Results: Of the 186 adult subjects with EoE, approximately 90% of patients tested positive to at least one food or aeroallergen. The top ten food allergens were peanut>almond>green pea>soybean>green bean>egg>pistachio nut>wheat>corn>yeast. Of the aeroallergens, dust mite, cat, and tree, grass, and weed pollen were positive in over 35% of subjects. At follow-up, 83% (95/119) reported improvement in dysphagia following recommendations of food elimination and treatment of coexisting allergic conditions. Histologic improvement (61%; 19/31) and histologic remission (52%; 6/31) occurred in subjects with repeat endoscopy. Conclusion: With the rise in use of empiric food elimination diets, this study would suggest that an allergy evaluation that includes aeroallergen and broad food testing can still play a role in adults with EoE. Many of the foods currently included in the six-food elimination diet were also prevalent by allergy skin testing with some additional foods identified including the broader legumes (pea and bean), corn, yeast, rice, onion, garlic, oat, sesame seed, and coconut. Thus, a broad environmental and food allergy testing appears to be a complementary strategy to aid in the management of patients with EoE, especially in patients whom have experienced either failure or compliance issues with the empiric six-food elimination diet.