Seasonal Variation in the Diagnosis of Eosinophilic Esophagitis: There and Back Again : Journal of Pediatric Gastroenterology and Nutrition

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Letters to the Editor

Seasonal Variation in the Diagnosis of Eosinophilic Esophagitis: There and Back Again

Lucendo, Alfredo J.; Molina-Infante, Javier; Arias, Ángel; González-Cervera, Jesús§

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Journal of Pediatric Gastroenterology and Nutrition 64(1):p e25, January 2017. | DOI: 10.1097/MPG.0000000000001417
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See “Correlation Between Aeroallergen Levels and New Diagnosis of Eosinophilic Esophagitis in New York City” by Fahey et al on page 22.

To the Editor: Although literature has shown conflicting results for aeroallergens as eosinophilic esophagitis (EoE) triggers, a recent systematic review combining data from 16,846 EoE patients (1) did not find significant variations in the seasonal distribution of either the initial diagnosis or clinical recrudescence of EoE throughout the year. As such, we read with interest the retrospective study by Fahey et al (2), which reports a positive correlation between peak levels of grass pollen with the onset of symptoms and diagnosis of new cases of EoE. The authors suggest that the potential role that environmental factors could play in EoE should be investigated as rigorously as that for food triggers. This association was not, however, shown for 10 additional pollen taxa. Beyond the risk of bias inherent to retrospective studies, we would like to make the case for the potential inaccuracy of a seasonal variation in EoE:

  • 1. Diagnostic delay in EoE is common (3) because patients usually minimize symptoms by modifying their eating behavior, whereas endoscopy is often performed after long waiting lists. Therefore, equating the onset of symptoms with the time of endoscopy performance can be somewhat deceiving.
  • 2. Outdoor season leads to different eating customs that might increase the risk of suffering from meat bolus impaction, leading to EoE diagnosis. Likewise, parents may gain increased awareness on their children symptoms during summer holidays because of spending more time together.
  • 3. Most EoE patients experience atopic conditions with regular visits to the allergy clinic during the pollen season. Accordingly, the opportunity of achieving an EoE diagnosis during the same season is highly likely.
  • 4. Although most atopic conditions are rapidly triggered after exposure to allergens by an immunoglobulin E–mediated mechanism, this is not the case for EoE (4). EoE is predominantly an immunoglobulin G4–associated food allergy (5), in which patients do not usually show immediate symptoms after exposure to offending foods.
  • 5. EoE is an antigen-induced disorder, predominantly but not exclusively triggered by food antigens. A 90% remission on an elemental formula (6) underscores a minor etiologic role for aeroallergens in EoE.
  • 6. EoE patients are usually sensitized to indoor perennial aeroallergens. EoE in murine models has only been replicated after exposure to mould, dust, and cockroach (7). Thus, conferring a predominant triggering role to seasonal pollen might be overly simplistic. Indoor allergens were not evaluated in this study.

In any case, whether airborne allergens play a causal or casual role in EoE should be elucidated in high-quality prospective studies.


1. Lucendo AJ, Arias A, Redondo-Gonzalez O, et al. Seasonal distribution of initial diagnosis and clinical recrudescence of eosinophilic esophagitis: a systematic review and meta-analysis. Allergy 2015; 70:1640–1650.
2. Fahey L, Robinson G, Weinberger K, et al. Correlation between aeroallergen levels and new diagnosis of eosinophilic esophagitis in New York City. J Pediatr Gastroenterol Nutr 2017; 64:22–25.
3. Lucendo AJ, Arias A, Molina-Infante J, et al. Diagnostic and therapeutic management of eosinophilic oesophagitis in children and adults: results from a Spanish registry of clinical practice. Dig Liv Dis 2013; 45:562–568.
4. Simon D, Cianferoni A, Spergel JM, et al. Eosinophilic esophagitis is characterized by a non-IgE-mediated food hypersensitivity. Allergy 2016; 71:611–620.
5. Clayton F, Fang JC, Gleich GJ, et al. Eosinophilic esophagitis in adults is associated with IgG4 and not mediated by IgE. Gastroenterology 2014; 147:602–609.
6. Arias A, Gonzalez-Cervera J, Tenias JM, et al. Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic esophagitis: a systematic review and meta-analysis. Gastroenterology 2014; 146:1639–1648.
7. Slack MA, Erwin EA, Cho CB, et al. Food and aeroallergen sensitization in adult eosinophilic esophagitis. Ann Allergy Asthma Immunol 2013; 111:304–305.
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