To the Editors:
Eosinophilic inflammation in the gastrointestinal tract is characterized histologically by the presence of increased numbers of eosinophils in gastrointestinal biopsies (1). Causes of eosinophilia vary depending on the location of the eosinophilia and include food allergies, chronic gastroesophageal reflux (when occurring in the esophagus), helminths, some connective tissue diseases (scleroderma), and drug injury (2). Often, no specific cause can be identified. Previously described treatments used for eosinophilic diseases of the gastrointestinal tract have included dietary restrictions primarily of cow milk protein (3), anti-inflammatory therapy utilizing suplatast, budesonide and corticosteroids (4–5), cromolyn sodium (6), antihistamines (7), and oral inhalable steroids (8). We describe 8 children with eosinophilic inflammation in the gastrointestinal tract unresponsive to standard therapies who exhibited marked improvement with use of montelukast (Singulair) (Table 1).
Our decision to use montelukast in our patients was based largely on the demonstrated efficacy of this agent in other eosinophilic conditions such as asthma (9). Cysteinyl leukotrienes (LTC4, LTD4, LTE4) are products of arachidonic metabolism released from mast cells and eosinophils. Cys LT1 selective antagonists, such as montelukast, inhibit physiologic actions of LTD4 without any agonist activity (10,11). Therefore, one could postulate a variety of abnormalities that occur in eosinophilic disorders in both the respiratory and GI tract that could be alleviated with the use of montelukast.
The use of montelukast has previously been described in an adult with eosinophilic gastroenteritis and in an adolescent female (12,13). The exact role of montelukast in the treatment of patients with gastrointestinal symptoms and gut eosinophilia cannot be determined from our series of patients. Most of our patients had received other, less-successful therapy directed at their specific disease process by the same team of physicians and health care personnel, which makes placebo effect a less likely explanation for the observed clinical improvement. A carefully designed and conducted double-blind, placebo-controlled study of montelukast for treating gastrointestinal eosinophilic disorders in children should be the next step to verify the excellent clinical response so far witnessed.
Jon A. Vanderhoof
Rosemary J. Young
Terri L. Hanner
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