Induction of Eosinophilic Esophagitis by Sublingual Pollen Immunotherapy
A 44-year-old female presented at our center with increasing dysphagia for 4 weeks. At the time of presentation, she reported having dysphagia for the first time in her life which occurred every day. Prior to this episode, the patient had never experienced any esophageal symptoms. Difficulties with swallowing required her to adapt her eating habits such as drinking liquids after swallowing food (dysphagia score 7 on a scale from 0 to 9). Her medical history revealed pollinosis since childhood and additional allergic asthma at the age of 22 years which improved for several years after subcutaneous immunotherapy. A deterioration occurred at the age of 42 years. At this time a total serum IgG of 757 U/ml was documented. Prick testing and specific serum IgE identified grass, rye, hazelnut, birch alder and oak as major allergens. Her family history was positive for pollinosis (mother and brother).\nFour weeks before the onset of dysphagia, the patient had begun SLIT with ORALVAC Compact (Bencard Allergie GmbH, Munich, Germany), a commercially available treatment considered to be safe []. The SLIT contained specific soluble allergens (hazelnut, birch, alder) according to previous specific serum IgE testing, administered sublingually as prescribed by the manufacturer's instructions. Upper endoscopy showed confluent whitish exudates and longitudinal red furrows in the proximal and the distal esophagus (fig. ). Biopsies from these lesions revealed a predominantly eosinophilic inflammation with a peak infiltration of 164 eosinophils per high power field (fig. ), which confirmed the diagnosis of EoE. Immediately after upper endoscopy, the patient discontinued SLIT, which led to complete resolution of dysphagia within 4 weeks without any other medical intervention. A follow-up endoscopy 4 weeks after withdrawal of SLIT demonstrated a macroscopically normal esophagus (fig. ). Biopsies from the proximal and distal esophagus revealed normal mucosa without any eosinophilic inflammation (fig. ). During a follow-up of 12 months the patient remained free of any esophageal symptoms.