Treatment of allergic esophagitis with budesonide turbuhaler*1

Rationale Eosinophilic esophagitis is an entity characterized by episodes of dysphagia and eosinophilic infiltration of the esophageal squamous epithelium on biopsy, with or without food sensitization. Treatment usually involves a combination of food avoidance and systemic corticosteroids, and more recently, use of oral corticosteroid inhalers. We report a case of eosinophilic esophagitis that was responsive to treatment with budesonide inhaler. Methods A seven year old male presented with a two year history of abdominal pain, dysphagia, and choking when eating solid foods. He also had a past medical history of atopic dermatitis and asthma. Allergy skin testing revealed sensitization to multiple foods, although the only food the patient was actively avoiding was peanuts. An open label food challenge with cow's milk was negative. Additional laboratory tests revealed mild peripheral blood eosinophilia (absolute eosinophil count 1,100/mm 3 ), peanut RAST of 6.7 IU/mL (Class 4), and an IgE level of 212 IU/mL. A barium swallow showed narrowing in the upper thoracic esophagus. Endoscopy revealed friable mucosa with exudates and a stiff esophagus. Histopathological examination demonstrated eosinophilia with >20 eosinophils/hpf. The patient was treated with budesonide turbuhaler two inhalations BID. Results Budesonide therapy resulted in dramatic improvement in his dysphagia within one week. Repeat endoscopy performed ten weeks later showed improvement in mucosal appearance and motility, and normal histopathology without eosinophilia. A repeat barium swallow was normal. Conclusions This case demonstrates the effectiveness of topical corticosteroid therapy in the treatment of eosinophilic esophagitis in a child.