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Month: March 2023

New Treatments for Eosinophilic Esophagitis

The esophagus is the muscular tube that propels food from the mouth into the stomach through a rhythmic, coordinated peristaltic action. The interior lumen of the tube is covered by a thin mucus membrane. This normal function can be impaired when the structure is chronically inflamed by various allergic triggers. A subset of white blood cells, called eosinophils, accumulate in the mucus membrane of the esophagus in response to the exposure of allergens that an individual is sensitized to. These eosinophils will release a number of chemical mediators of inflammation into the tissues causing structural and functional damage. When this occurs, the individual has a condition called eosinophilic esophagitis (EoE).

Eosinophilic esophagitis is a relatively newly recognized condition. It has been increasingly diagnosed in adults and children over the past couple of decades. The frequency of eosinophilic esophagitis has been estimated to be approximately 1 in 2,000 individuals.

Food allergens are the most common cause of eosinophilic esophagitis. Though any food can be an allergen in theory, the most commonly implicated foods in patients with eosinophilic esophagitis are milk, wheat, soy, eggs, peanuts, tree nuts, and fish/shellfish. Individuals with eosinophilic esophagitis often have other allergic diseases such as allergic rhinitis (i.e., hay fever), asthma and/or eczema (i.e., atopic dermatitis).

Genetic factors play a role in the causation of eosinophilic esophagitis as the condition is known to run in families. Some individuals with this condition have been found to have an unusually high expression of a particular gene named eotaxin-3.


The symptoms of eosinophilic esophagitis ay vary by the age of the patient as well as the severity of the inflammation. The main symptoms are listed below:

  • Difficulty swallowing (i.e., dysphagia)
  • Food getting stuck in the throat (impaction)
  • Nausea/vomiting
  • Abdominal pain
  • Poor appetite/weight loss


The diagnosis is often delayed because of a lack of awareness of this condition. A high index of suspicion is needed for the detection of eosinophilic esophagitis in both children and adults presenting with above symptoms.

In order to confirm the diagnosis of eosinophilic esophagitis, it is necessary to do an upper endoscopy, where a thin flexible tube with a light source is passed into the esophagus through the mouth in order to visualize the esophagus. The appearance of whitish patches (i.e., plaques), furrows, and in late stages, circular rings resulting from scarring, are highly suggestive of eosinophilic esophagitis. Multiple biopsies are needed of the inner esophagus during this procedure. The diagnosis is conclusively established by the demonstration of the excessive accumulation of eosinophils in the biopsy specimens obtained from the esophagus.

Environmental allergies to substances such as pollens, animals, dust mites, and molds possibly play a role in eosinophilic esophagitis. For some patients, it may seem like their eosinophilic esophagitis is worse during pollen seasons. Allergy testing for these common environmental allergens is often part of an eosinophilic esophagitis evaluation.


The treatment of eosinophilic esophagitis involves a variety of approaches:

1. Dietary Modifications:

  • 6 food (i.e., diary, egg, wheat, soy, nuts, seafood) elimination diet
  • Elimination of foods based on allergy skin prick and/or patch testing
  • Elemental (i.e., amino acid) diet

If the symptoms improve while on dietary restriction, foods can be gradually be reintroduced, one food at a time, while closely monitoring for the relapse of symptoms.

2. Drug Therapy:

  • Proton pump inhibitors (e.g., Prilosec, Nexium) improve symptoms in a subset of patients either by reducing the excessive acid production or more likely by a direct anti-inflammatory action over the esophagus.
  • Topical inhaled corticosteroid medications such as fluticasone (i.e., Flovent) and budesonide (i.e., Pulmicort). These are approved only as inhaled anti-inflammatory agents for asthma, but are used off-label as ingestible medications for eosinophilic esophagitis. These medications coat the mucus membrane, reduce the eosinophilic inflammation, and lead to symptom improvement.
  • Additional endoscopies and biopsies are usually necessary to monitor the effectiveness of treatment.

3. Biological Medications:

In 2022, dupilumab (i.e., Dupixent) was approved by the U.S. Food and Drug Administration (FDA) to treat adults and children 12 years and older with eosinophilic esophagitis. This is the first FDA-approved treatment for eosinophilic esophagitis.

Dupixent is administered by injection under the skin once a week. This medication reduces the number of eosinophils in the esophagus and can lead to significant relief from symptoms.


Families often benefit from participating in support groups and organizations. The American Partnership for Eosinophilic Disorders (APFED) and Campaign Urging Research for Eosinophilic Disease (CURED) are two lay organizations that provide valuable reliable resources for individuals with eosinophilic esophagitis.

The board certified allergy doctors at Black & Kletz Allergy have been diagnosing and treating eosinophilic esophagitis in both adults and children in patients in the Washington, DC, Northern Virginia, and Maryland metropolitan area for many years. Black & Kletz Allergy has 3 offices in the Washington, DC metro area with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. We offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. If you suffer from difficulty swallowing, food getting stuck in your throat, or any other symptom related to eosinophilic esophagitis, please call us to make an appointment at one of our conveniently located offices. Alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day. The allergists at Black & Kletz Allergy are confident that we will be able to help you get to the bottom of your problem as well as treat this gastrointestinal disorder. We have been serving the Washington, DC metro area for more than 50 years in the field of allergy, asthma, and immunology and we hope to improve your quality of life by reducing or preventing your unwanted and bothersome allergy symptoms.

Pollen Food Allergy Syndrome

Pollen Food Allergy Syndrome (also called pollen food allergy syndrome) is a condition where there is a cross reaction to allergens that are found both in pollen and certain foods. The most common foods associated with pollen food allergy syndrome include fresh fruits, vegetables, and some tree nuts. The disorder affects roughly one-third of individuals with seasonal allergic rhinitis (i.e., hay fever).

The primary inner workings of pollen food allergy syndrome is a genetically determined “sensitization” of the immune system to various pollens and the ensuing “reactions” when exposed to these pollens. The immune system sees these pollens as “foreign” and consequently reacts against them resulting in the irritating symptoms of hay fever. The immune system recognizes the pollen as well as similar proteins in the food and then subsequently directs an allergic response to the allergenic protein. An easy way to think of it is that your body sees the food as the pollen since the allergenic proteins of the food is very similar to the allergenic proteins of the pollen. If you are allergic to a pollen such as birch tree pollen, you will then mount an allergic response to a cross-reacting food such as a raw fresh apple even though you are not allergic to that food (i.e., apple) because your body normally mounts a response to that birch tree pollen. It is important to note that in most instances, the person can eat the food if it is cooked (i.e., baked apple) without allergic symptoms. The reason individuals can usually eat the cooked version of the food is because the heating process changes the structure of the protein of the food so it looks different structurally. This structurally changed food protein is not recognized by the immune system as a protein that is similar to the pollen, and thus no allergic reaction occurs.

The symptoms of pollen food allergy syndrome may include itching of the lips, tongue, gums, palate and/or throat after eating raw fresh fruits, vegetables, and/or some tree nuts (i.e., almond, hazelnut). The symptoms usually start within a few minutes after eating the raw fresh fruits, vegetables, and/or tree nut and generally abates within a few hours. The symptoms of pollen food allergy syndrome are usually minimal, but in rare cases, they can cause throat swelling and/or difficulty in swallowing. Such severe reactions are more likely to occur with peanuts and/or tree nuts. It is important to establish that some people with itchy lips, mouth and/or throat after eating a raw fresh specific fruit, vegetable, and/or tree nut may in fact have a true food allergy to a specific fruit, vegetable and/or tree nut and not have pollen food allergy syndrome. These “real” food-allergic individuals usually will have the same or comparable symptoms even when eating the fruit/vegetable cooked, unlike patients with pollen food allergy syndrome who can usually tolerate the cooked fruit/vegetable without symptoms.

Pollen food allergy syndrome tends to be more prominent and bothersome in the Spring months when one is exposed to higher levels of pollen. Specific tree pollen sensitivity cross-reacts with specific fruit/vegetable/tree nut proteins due to the closeness in the amino acid sequences of the allergenic proteins. For example, patients with birch pollen sensitivity tend to react more commonly with fresh raw pitted fruits (e.g., apples, peaches, pears, apricots, plums) as well as carrots, peanuts, and/or tree nuts. Individuals with allergies to grasses may have a reaction to celery, peaches, melons, (e.g., watermelon, honeydew, cantaloupe), oranges, and tomatoes. Ragweed pollen sensitivity in the Fall usually cross-reacts with bananas, melons, cucumbers, and/or zucchini.

The diagnosis of pollen food allergy syndrome is made commonly by a history of oral pruritus (i.e., itching) and irritation in individuals who have previously tested positive for allergies to pollen and are symptomatic during the corresponding pollen seasons.

The treatment of pollen food allergy syndrome involves evading the offending raw fresh fruits/vegetables/tree nut. Peeling the skin before eating and/or cooking (i.e., baking, microwaving) before eating the food may reduce the severity of the symptoms, as heat denatures the allergenic protein which thus decreases its allergenic potential.

The board certified allergy doctors at Black & Kletz Allergy have expertise in diagnosing and treating pollen food allergy syndrome as well as food allergies. . We are board certified to diagnose and treat both adult and pediatric patients and we have been doing so in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than a half a century. Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking. For additional convenience, our Washington, DC and McLean, VA offices are Metro accessible. Our McLean office location offers a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line. For an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from food allergies, food sensitivities, or pollen food allergy syndrome we are here to help improve your life by preventing unwanted food-related symptoms that have been so troublesome. Black & Kletz Allergy is devoted to providing the highest quality allergy care in a comfortable, compassionate, and professional environment.