Natural Histories and Disease Complications in a Cohort of 151 Children With Gastric or Duodenal Eosinophilia.

INTRODUCTION: Eosinophilic gastritis (EoG) and duodenitis (EoD) are rare conditions that are poorly understood. Our aim was to describe the natural history of children with varying degrees of gastric or duodenal eosinophilia with respect to disease complications and histologic and endoscopic longitudinal trajectories. METHODS: The electronic medical record at a tertiary children's hospital was queried to identify patients with EoG, EoD, or EoG + EoD who were cared for between January 2010 and 2022. Multiple logistic regression was performed to explore associations between baseline features and persistence/recurrence of eosinophilia or complications remote from diagnosis. RESULTS: We identified 151 patients: 92 with EoG, 24 with EoD, 12 with EoG + EoD, and 23 with tissue eosinophilia but did not meet histologic criteria for EoG or EoD (low grade). The average age at diagnosis was 10.6 years, and average follow-up was 5.8 years. Twenty-five percent of patients with EoG or EoD had persistence/recurrence of eosinophilia; this was associated with increases in the EoG Endoscopic Reference Score (adjusted odds ratio [aOR] 1.34, confidence interval [CI] 1.03-1.74) on diagnostic endoscopy. Eighteen percent suffered from disease complications, and development of late complications was associated with presenting with a complication (aOR 9.63, CI 1.09-85.20), severity of duodenal endoscopic abnormalities (aOR 8.74, CI 1.67-45.60), and increases in the EoG Endoscopic Reference Score (aOR 1.70, CI 1.11-2.63). DISCUSSION: Patients with gastric and duodenal eosinophilia should be followed closely to monitor for recurrence and complications, especially those presenting with endoscopic abnormalities or complications.

Utilization and impact of esophageal string testing in children with eosinophilic esophagitis: A 1 year experience.

The 1-h esophageal string test (EST) is a minimally invasive test that can be used to monitor eosinophilic esophagitis (EoE) disease activity and guide treatment without endoscopy. We aimed to describe the real-world utilization and impact of EST on the care of children with EoE over the first year this was used at our center. Between 12/1/2022 and 11/30/2023, 39 ESTs were successful in 45 attempts (87% completion rate) in 31 patients. Five patients underwent multiple ESTs. Adverse events during the EST included vomiting. Reasons for failure to complete the EST (13%, n = 6) were patients could not swallow the capsule (n = 5) and vomiting (n = 1). EST was used to assess EoE without the need for endoscopy in 95% (n = 37) of cases. Treatment approach varied based on whether the EST indicated active (38.5%) or inactive (61.5%) EoE. The EST is a well-tolerated minimally invasive disease monitoring tool for patients with EoE.

The role of biologics in pediatric food allergy and eosinophilic gastrointestinal disorders.

Continuing insight into the molecular mechanisms of atopic disorders has enabled the development of biologics to precisely target these diseases. Food allergy (FA) and eosinophilic gastrointestinal disorders (EGIDs) are driven by similar inflammatory molecular mechanisms and exist along the same atopic disease spectrum. Therefore, many of the same biologics are being investigated to target key drivers of mechanisms shared across the disease states. The enormous potential of biologics for the treatment of FA and EGIDs is highlighted by the significant increases in the number of ongoing clinical trials (more than 30) evaluating their use in these disease states, as well as by the recent US Food and Drug Administration approval of dupilumab for the treatment of eosinophilic esophagitis. Here we discuss past and current research into the use of biologics in FA and EGIDs and their potential role in improving treatment options in the future, with the need to have biologics widely clinically available.

Breakthroughs in understanding and treating eosinophilic gastrointestinal diseases presented at the CEGIR/TIGERs Symposium at the 2022 American Academy of Allergy, Asthma & Immunology Meeting.

The Consortium of Eosinophilic Gastrointestinal Diseases and The International Gastrointestinal Eosinophil Researchers organized a day-long symposium at the 2022 Annual Meeting of the American Academy of Allergy, Asthma & Immunology. The symposium featured a review of recent discoveries in the basic biology and pathogenesis of eosinophilic gastrointestinal diseases (EGIDs) in addition to advances in our understanding of the clinical features of EGIDs. Diagnostic and management approaches were reviewed and debated, and clinical trials of emerging therapies were highlighted. Herein, we briefly summarize the breakthrough discoveries in EGIDs.

Accidental ingestions to known allergens by food allergic children and adolescents.

BACKGROUND: Accidental ingestions (AI) of food allergens in children compared with adolescents with food allergies are poorly characterized. It is suggested that AIs are higher in adolescents than children and that their reactions may be more severe, presumptively due, at least in part, to increased risk-taking behavior. We compared reported AIs in children versus adolescents. METHODS: An online cross-sectional survey was distributed to parents of children with food allergies via Twitter, food allergy advocacy groups in the UK, South Africa, and Australia, and locally at Children's Hospital Colorado. RESULTS: Of 558 respondents, 105 were parents of adolescents, and 453 had children <12 years. 73% (341) reported an AI since diagnosis, with 85% of adolescents having had an AI versus 70% of children (p = 0.0058). The annualized rate of AI was significantly lower in the adolescent population at 0.21 versus 0.53 in children (p = <0.0001). Although adolescents reported fewer severe reactions (2% vs. 16%, p = 0.0283), more adolescents required epinephrine administered by a medical professional for their most severe AI, (48% vs. 24%, p = 0.0378). Comparison of the two age groups is limited by the fact that many AIs in the adolescent group occurred prior to age 12. There was no significant difference between the groups as to where the food was consumed or the type of food. There was a significant difference in accidental ingestions in patients in all age groups with more than one reported food allergy; 78% of those with more than one food allergy reported a prior history of at least one accidental ingestion, compared with 59% in those with a single food allergy (p < 0.0001). Regional differences were also noted with respondents in the United States reporting 0.3 accidental ingestions a year, 0.4 in the UK, and 0.5 in other countries (p = 0.0455). The number of reactions was, on average, 27% lower (95% CI: 40, 11%) in the United States compared with the UK (p = 0.0019). CONCLUSION: The number of severe reactions, and epinephrine need, differs in children compared with adolescents, although many of the reported reactions in both groups occurred before the age of 12. There were also regional differences with the United States reporting a lower number of AIs and less AIs per year than the other participating regions, as well as increased rates of AI in participants with more than one food allergy. Further characterization of the differences in AIs between children and adolescents, as well as between regions, is needed to assist with more patient-centered anticipatory guidance.

Clinical Evaluation of the Child with Eosinophilic Esophagitis.

The diagnosis of eosinophilic esophagitis (EoE) is based on clinical symptoms of esophageal dysfunction and eosinophil predominant esophageal inflammation. Clinical symptoms in children with EoE vary based on age and may be nonspecific. EoE has a male predominance with the majority having comorbid atopic disorders. At present, treatment options include medications (proton pump inhibition, swallowed topical steroids), dietary therapy or biologic therapy (dupilumab, approved for those ≥12 years of age). Outside of EoE in the context of oral immunotherapy, EoE is typically chronic requiring lifelong therapy. Long-term complications including feeding difficulties, malnutrition, and fibrostenotic disease.

Identifying Children at Risk of Growth and Nutrient Deficiencies in the Food Allergy Clinic.

BACKGROUND: Food allergies affect growth in children by decreasing the availability of nutrients through decreased dietary intake, increased dietary needs, food-medication interactions, and psychosocial burden. Guidelines on food allergy management frequently recommend nutrition counseling and growth monitoring of children with food allergies. OBJECTIVE: To provide clear guidance for clinicians to identify children with food allergies who are at nutritional risk and ensure prompt intervention. METHODS: We provide a narrative review summarizing information from national and international guidelines, retrospective studies, population studies, review articles, case reports, and case series to identify those with food allergy at greatest nutritional risk, determine the impact of nutritional interventions on growth, and develop guidance for risk reduction in children with food allergies. RESULTS: Children with food allergies are at increased risk of nutritional deficiencies and poor growth. Nutritional assessment and intervention can improve outcomes. Identifying poor growth is an important step in the nutrition assessment. Therefore, growth should be assessed at each allergy evaluation. Interventions to ensure adequate dietary intake for growth include appropriately prescribed elimination diets, breast-feeding support and assessment, supplemental formula, vitamin and/or mineral supplementation, appropriate milk substitutes, and timely introduction of nutrient-dense complementary foods. Access to foods of appropriate nutritional value is an ongoing concern. CONCLUSION: Nutrition intervention or referral to registered dietitian nutritionists with additional training and/or experience in food allergy may result in improved growth and nutrition outcomes.

A case of food and aeroallergen sublingual immunotherapy inducing eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) has been reported secondary to aeroallergen sublingual immunotherapy (SLIT) and food allergen oral immunotherapy. Gastrointestinal symptoms with food allergen SLIT are uncommon, with no prior reports of cases of food allergen SLIT inducing EoE. Here we report a patient who developed EoE secondary to food and aeroallergen SLIT therapy that resolved with SLIT cessation.

The Challenges of Managing Multiple Food Allergies and Consequent Food Aversions.

The allergic march can often result in children with one food allergy phenotype developing other allergic manifestations as they grow older. In this grand round, we describe the case of a child with a diagnosis of eosinophilic esophagitis at an early age, who subsequently developed IgE-mediated allergy to milk and egg. Because of the onset of allergic rhinitis, an additional complication of the teenage years was the development of pollen food syndrome, which further affected the already complex dietary management. These multiple allergies had a consequent effect on nutritional status and provoked considerable psychosocial issues, which greatly affected the patient's relationship with food. This case illustrates that for complex patients, a cohesive approach and shared decision-making are essential for diagnosis and management. Working with the patient and also the whole family, and considering how best to support them, necessitates a flexible approach. Regular follow-up is important to address changing psychosocial and dietary needs and monitor the resolution of allergies and response to pharmacotherapy. Complex patients need the input of a comprehensive multidisciplinary team, with good access to dietetic and psychological support, to optimize quality of life for these individuals and their families.

Minimizing the "Kitchen Sink" Approach: De-implementation of Unnecessary Care for Patients with Anaphylaxis in a Pediatric Emergency Department.

Epinephrine is the only medication that prevents morbidity and mortality in anaphylaxis. Systemic corticosteroids and H2 receptor antagonists (H2RA) may benefit select cases but are not universally indicated. This study aims to de-implement the universal use of steroids and H2RAs and emphasize epinephrine-focused care for children with anaphylaxis during acute care visits. The study aims to reduce steroid and H2RA use from 81% and 60%, respectively, to 30% by December 2019. Methods: The primary outcome measures were the percent of patients receiving steroids and H2RAs in the emergency department (ED) or urgent care (UC). Process measure was the frequency of intravenous (IV) line placement. Balancing measures were ED/UC length of stay, admission rate, and ED/UC return visit rate. In addition, a multidisciplinary team designed the following interventions: (1) anaphylaxis clinical pathway to emphasize epinephrine-focused care, outline criteria for second-line therapies and a provider guideline for ED/UC observation; (2) standardize unit-based anaphylaxis medication kits; (3) optimize electronic medical record tools, including order sets and discharge instructions to be concordant with guideline recommendations. Results: The study included 870 patients. There was special cause variation in the use of steroids (81%-33%) and H2RAs (60%-11%), ED/UC Length of stay decreased (6.2-5.0 hours). There was no special cause variation in admission rates or ED/UC return visit rates. Conclusion: Universal use of systemic steroids and H2RAs can be safely de-implemented in pediatric patients with anaphylaxis using quality improvement methods.

A Multidisciplinary Quality Improvement Initiative to Facilitate Penicillin Allergy Delabeling Among Hospitalized Pediatric Patients.

BACKGROUND: Penicillin allergy is reported in up to 10% of the general population; however, >90% of patients reporting an allergy are tolerant. Patients labeled as penicillin allergic have longer hospital stays, increased exposure to suboptimal antibiotics, and an increased risk of methicillin-resistant Staphylococcus aureus and Clostridioides difficile. The primary aim with our quality improvement initiative was to increase penicillin allergy delabeling to at least 10% among all hospitalized pediatric patients reporting a penicillin allergy with efforts directed toward patients determined to be low risk for true allergic reaction. METHODS: Our quality improvement project included several interventions: the development of a multidisciplinary clinical care pathway to identify eligible patients, workflow optimization to support delabeling, an educational intervention, and participation in our institution's quality improvement incentive program. Our interventions were targeted to facilitate appropriate delabeling by the primary hospital medicine team. Statistical process control charts were used to assess the impact of this intervention pre- and postpathway implementation. RESULTS: After implementation of the clinical pathway, the percentage of patients admitted to hospital medicine delabeled of their penicillin allergy by discharge increased to 11.7%. More than one-half of those delabeled (51.2%) received a penicillin-based antimicrobial at time of discharge. There have been no adverse events or allergic reactions requiring emergency medication administration since pathway implementation. CONCLUSIONS: Our quality improvement initiative successfully increased the rate of penicillin allergy delabeling among low-risk hospitalized pediatric patients, allowing for increased use of optimal antibiotics.

An adolescent girl with signs and symptoms of anaphylaxis and negative immunologic workup: a case report.

BACKGROUND: The increasing incidence of allergies and allergic reactions among children and adults has become a major public health concern. The etiology of allergic reactions can often be confirmed based on a detailed history and supportive testing. However, there are cases where the underlying factors are more complex and difficult to identify. CASE PRESENTATION: Here we present the case report of a 14-year-old Caucasian  girl with weight loss and a 3-year history of reported angioedema culminating in five intensive care unit admissions over the course of 2.5 months. Her initial clinical presentation included hypotension, dyspnea, and reported facial edema, but allergy and immunological workup were negative. A psychiatric workup identified an eating disorder with food restriction, comorbid major depression, obsessive compulsive disorder, and posttraumatic stress disorder. A close collaboration between Adolescent Medicine, Allergy and Immunology, and Psychiatry helped disentangle medical from psychiatric problems, including fluoxetine medication effects, as well as develop a treatment plan that was acceptable to the family. The angioedema was ultimately diagnosed as factitious disorder. CONCLUSIONS: This patient's treatment highlights the importance of a multidisciplinary team approach, a multifactorial etiology that needed to be addressed by multiple specialists, and the importance of long-term treatment and support.

Cytological evaluation correlates poorly with histological diagnosis of vulvar neoplasias.

OBJECTIVE: To determine whether cytological smears of the vulva correlate with vulvar biopsies of vulvar intraepithelial neoplasias (VINs). MATERIALS AND METHODS: A retrospective chart review (1995-2000) was performed to identify cases of VIN and vulvar carcinoma and to correlate vulvar Pap smears with biopsy results. RESULTS: Four hundred vulvar Pap smears were identified. Fifty of these patients had concomitant vulvar biopsies, and these cases constitute our study group. Twenty-two of these 50 women had biopsy-proven VIN or vulvar carcinoma. Only 7 (32%) of 22 patients with biopsy-proven disease had a vulvar Pap smear significant for VIN or vulvar carcinoma. The kappa statistic was 0.30 (95% CI=0.08-0.52), indicating poor agreement between vulvar cytology and biopsy results. CONCLUSIONS: Vulvar cytological evaluation did not correlate well with tissue diagnosis of VIN; and thus, our findings do not support the use of vulvar cytology in the clinical management of VIN.