SpringerLink
Log in

Sublingual immunotherapy for cedar pollinosis possibly triggers eosinophilic esophagitis

  • Case Report
  • Published:
Clinical Journal of Gastroenterology Aims and scope Submit manuscript

Abstract

Sublingual immunotherapy (SLIT) is an effective and popular treatment for cedar pollinosis. Although SLIT can cause allergic side effects, eosinophilic esophagitis (EoE) is a lesser-known side effect of SLIT. A 26-year-old male with cedar pollinosis, wheat-dependent exercise-induced anaphylaxis, and food allergies to bananas and avocados presented with persistent throat itching, difficulty swallowing, heartburn, and anterior chest pain 8 days after starting SLIT for cedar pollinosis. Laboratory examination showed remarkably elevated eosinophils, and esophagogastroduodenoscopy revealed linear furrows in the entire esophagus. Histological examination of an esophageal biopsy specimen revealed high eosinophil levels. The patient was strongly suspected with EoE triggered by SLIT. The patient was advised to switch from the swallow to the spit method for SLIT, and the symptoms associated with SLIT-triggered EoE were reduced after switching to the spit method. This case highlights the importance of recognizing SLIT-triggered EoE as a potential side effect of SLIT for cedar pollinosis, especially with the increasing use of SLIT in clinical practice. EoE can occur within a month after initiating SLIT in patients with multiple allergic conditions, as observed in our case. Furthermore, the spit method should be recommended for patients who experience SLIT-triggered EoE before discontinuing SLIT.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Dellon ES, Liacouras CA, Molina-Infante J, et al. Updated international consensus diagnostic criteria for eosinophilic esophagitis: proceedings of the AGREE conference. Gastroenterology. 2018;155:1022-1033.e10.

    Article  PubMed  Google Scholar 

  2. Spergel J, Aceves SS. Allergic components of eosinophilic esophagitis. J Allergy Clin Immunol. 2018;142:1–8.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Alexander ES, Martin LJ, Collins MH, et al. Twin and family studies reveal strong environmental and weaker genetic cues explaining heritability of eosinophilic esophagitis. J Allergy Clin Immunol. 2014;134:1084-1092.e1.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Ito Y, Kato T, Yoshida K, et al. Prevalence of alergic dseases across all ages in Japan: a nationwide cross-sectional study employing designated allergic disease medical hospital network. JMA J. 2023;6:165–74.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Horn A, Bernstein DI, Okubo K, et al. House dust mite sublingual immunotherapy tablet safety in adolescents with allergic rhinoconjunctivitis: clinical trial results. Ann Allergy Asthma Immunol. 2023;130:797–804.

    Article  CAS  PubMed  Google Scholar 

  6. Nolte H, Casale TB, Lockey RF, et al. Epinephrine use in clinical trials of sublingual immunotherapy tablets. J Allergy Clin Immunol Pract. 2017;5:84–9.

    Article  PubMed  Google Scholar 

  7. Matsushita T, Maruyama R, Ishikawa N, et al. The number and distribution of eosinophils in the adult human gastrointestinal tract: a study and comparison of racial and environmental factors. Am J Surg Pathol. 2015;39:521–517.

    Article  PubMed  Google Scholar 

  8. Dellon ES, Gonsalves N, Abonia JP, et al. International consensus recommendations for eosinophilic gastrointestinal disease nomenclature. Clin Gastroenterol Hepatol. 2022;20:2474-2484.e3.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Wise SK, Damask C, Roland LT, et al. International consensus statement on allergy and rhinology: Allergic rhinitis—2023. Int Forum Allergy Rhinol. 2023;13:293–859.

    Article  PubMed  Google Scholar 

  10. Gilles S, Akdis C, Lauener R. The role of environmental factors in allergy: a critical reappraisal. Exp Dermatol. 2018;27:1193–200.

    Article  PubMed  Google Scholar 

  11. Sakashita M, Tsutsumiuchi T, Kubo S, et al. Comparison of sensitization and prevalence of Japanese cedar pollen and mite-induced perennial allergic rhinitis between 2006 and 2016 in hospital workers in Japan. Allergol Int. 2021;70:89–95.

    Article  PubMed  Google Scholar 

  12. Meltzer EO. Allergic rhinitis: burden of illness, quality of life, comorbidities, and control. Immunol Allergy Clin North Am. 2016;36:235–48.

    Article  PubMed  Google Scholar 

  13. Crystal-Peters J, Crown WH, Goetzel RZ, et al. The cost of productivity losses associated with allergic rhinitis. Am L Manag Care. 2000;6:373–8.

    CAS  Google Scholar 

  14. Dellon ES, Jensen ET, Martin CF, et al. Prevalence of eosinophilic esophagitis in the United States. Clin Gastroenterol Hepatol. 2014;12:589-96.e1.

    Article  PubMed  Google Scholar 

  15. Lucendo AJ, Molina-Infante J, Arias Á, et al. Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterol J. 2017;5:335–58.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Furuta GT, Katzka DA. Eosinophilic esophagitis. N Engl J Med. 2015;22(373):1640–8.

    Article  Google Scholar 

  17. Cafone J, Capucilli P, Hill DA, et al. Eosinophilic esophagitis during sublingual and oral allergen immunotherapy. Curr Opin Allergy Clin Immunol. 2019;19:350–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Egan M, Atkins D. What is the relationship between eosinophilic esophagitis (EoE) and aeroallergens? Implications for allergen immunotherapy. Curr Allergy Asthma Rep. 2018;16(18):43.

    Article  Google Scholar 

  19. Fujiwara Y, Tanaka F, Sawada A, et al. A case series of sublingual immunotherapy-induced eosinophilic esophagitis: stop or spit. Clin J Gastroenterol. 2021;14:1607–11.

    Article  PubMed  Google Scholar 

  20. Suto D, Murata K, Otake T, et al. Eosinophilic esophagitis induced by sublingual immunotherapy with cedar pollen: a case report. Asia Pac Allergy. 2021;11:e44.

  21. Miehlke S, Alpan O, Schröder S, Straumann A. Induction of eosinophilic esophagitis by sublingual pollen immunotherapy. Case Rep Gastroenterol. 2013;7:363–8.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Antico A, Fante R. Esophageal hypereosinophilia induced by grass sublingual immunotherapy. J Allergy Clin Immunol. 2014;133:1482–4.

    Article  PubMed  Google Scholar 

  23. Béné J, Ley D, Roboubi R, et al. Eosinophilic esophagitis after desensitization to dust mites with sublingual immunotherapy. Ann Allergy Asthma Immunol. 2016;116:583–4.

    Article  PubMed  Google Scholar 

  24. Rokosz M, Bauer C, Schroeder S. Eosinophilic esophagitis induced by aeroallergen sublingual immunotherapy in an enteral feeding tube-dependent pediatric patient. Ann Allergy Asthma Immunol. 2017;119:88–9.

    Article  PubMed  Google Scholar 

  25. Kawashima K, Ishihara S, Masuhara M, et al. Development of eosinophilic esophagitis following sublingual immunotherapy with cedar pollen extract: a case report. Allergol Int. 2018;67:515–7.

    Article  PubMed  Google Scholar 

  26. Nucera E, Urbani S, Buonomo A, et al. Eosinophilic esophagitis during latex desensitization. J Investig Allergol Clin Immunol. 2020;30:61–3.

    Article  CAS  PubMed  Google Scholar 

  27. Wells R, Fox AT, Furman M. Recurrence of eosinophilic oesophagitis with subcutaneous grass pollen immunotherapy. BMJ Case Rep. 2018, 2018: bcr-2017–223465.

  28. Skrabski F, Pérez-Pallisé ME, Domínguez Estirado A, et al. Eosinophilic esophagitis caused by grass pollen sublingual immunotherapy with tolerance to a subcutaneous extract. J Investig Allergol Clin Immunol. 2022;22(32):315–7.

    Article  Google Scholar 

  29. Dellon ES, Gibbs WB, Fritchie KJ, et al. Clinical, endoscopic, and histologic findings distinguish eosinophilic esophagitis from gastroesophageal reflux disease. Clin Gastroenterol Hepatol. 2009;7:1305–13.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Gastroenterology, Kumamoto City Hospital, 4-1-60, Higashimachi, Higashi-Ku, Kumamoto City, Kumamoto, 862-8505, Japan

    Toshio Yamagata, Hirokazu Saito, Atsushi Fujimoto, Kana Oomoto, Akiko Ikebata, Motohiko Tanaka, Shuji Tada & Shunpei Hashigo

  2. Department of Radiology, Kumamoto City Hospital, 4-1-60, Higashimachi, Higashi-Ku, Kumamoto City, Kumamoto, 862-8505, Japan

    Joji Urata

  3. Department of Diagnostic Pathology, Kumamoto City Hospital, 4-1-60, Higashimachi, Higashi-Ku, Kumamoto City, Kumamoto, 862-8505, Japan

    Yasuo Toyozumi

Authors
  1. Toshio Yamagata
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hirokazu Saito
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Atsushi Fujimoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kana Oomoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Akiko Ikebata
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Joji Urata
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Motohiko Tanaka
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yasuo Toyozumi
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Shuji Tada
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Shunpei Hashigo
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hirokazu Saito.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Human/animal rights

All procedures followed have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Informed consent

Informed consent was obtained from the patient in this report.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yamagata, T., Saito, H., Fujimoto, A. et al. Sublingual immunotherapy for cedar pollinosis possibly triggers eosinophilic esophagitis. Clin J Gastroenterol 17, 6–11 (2024). https://doi.org/10.1007/s12328-023-01881-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12328-023-01881-z

Keywords

Search

Navigation