The Role of Food Allergy in Eosinophilic Esophagitis

Figures & data

Table 1 Evidence That EoE is a Form of Chronic Food Allergy

Form of Evidence	Finding
Epidemiologic	EoE is highly associated with allergic diseases, including IgE-mediated food allergies
	EoE is reported in ~3% of individuals with a history of FA undergoing oral immunotherapy; Symptoms and esophageal inflammation normalize upon discontinuing immunotherapy
	EoE has been reported in subjects with a history of FA who achieve natural “tolerance” and consistently introduce the culprit food into their diet; Removal of the offending food results in remission of EoE
Immune specificity	Inflammatory milieu in esophagus is enriched for cytokines, antibodies and cells associated with allergic (ie – Th2-related) immunity
	Presence of antibodies (IgE and IgG4) and T cells which recognize food allergens that are causally-related with EoE
Diet specificity	Avoidance of specific foods can lead to disease remission
Reversibility	Re-introduction of specific foods leads to recurrence of disease

Table 2 Summary of Characteristics in EoE and IgE-Mediated Food Allergy

Characteristics	IgE-Mediated Food Allergy	Eosinophilic Esophagitis
Sensitization site	Good evidence for Skin; airway or gut may contribute	Uncertain
Effector site	Gut, skin, cardiovascular and respiratory systems	Esophagus
Major allergens in adult patients	Peanut = tree nuts > shellfish >> cow’s milk	Cow’s milk > wheat = egg > soy
Relevant genes	Filaggrin, HLA, IL-13, TSLP, STAT6	TSLP, Calpain 14, LRRC32, EMSY, STAT6
Environmental Factors	Early acid suppression medications and delayed exposure to allergenic foods	C-section, early antibiotics and acid suppression medications
Specific Antibodies	IgE ^high, IgG4 ^low	IgE ^low, IgG4 ^high
T cells	Th2 and Treg	Th2 and Treg
Effector Cells	Mast cells, basophils?	Eosinophils, mast cells

Figure 1 EoE is a local inflammatory disease of the esophagus and FA is a systemic allergic disorder, but both represent a continuum of food-related allergic disease. Th2 cells and Tregs are present in different relative amounts, but share similar surface markers and cytokine-expression profiles in both EoE and FA. Food-specific IgE and IgG4 are common in both EoE and FA, but the relative ratio of IgE is higher in FA. Changes that occur with diet or treatment (eg, oral immunotherapy) will influence the adaptive immune response and may change the dynamic equilibrium between EoE and FA.

Notes: Adapted from Annals of Allergy, Asthma & Immunology, Vol 22/edition 6, McGowan EC, Platts-Mills TAE, Wilson JM. Food allergy, eosinophilic esophagitis, and the enigma of IgG4, pages 563–564, Copright 2019, with permission from Elsevier.⁸²

McGowan EC, Platts-Mills TAE, Wilson JM. Food allergy, eosinophilic esophagitis, and the enigma of IgG4. Ann Allergy Asthma Immunol. 2019;122(6):563–564. doi:10.1016/j.anai.2019.03.02430928417

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