Conclusion that summarizes the letter:
The frequency of cough as an atypical symptom of eosinophilic esophagitis is low and is characterized by the fact that it is usually daytime and irritative, especially during or after food intake
Eosinophilic esophagitis and chronic cough originated beyond the respiratory tree
CC affects all age groups and is a common complaint in the allergist practice.
Eosinophilic esophagitis (EoE) is a clinicopathologic disease characterized by esophageal dysfunction symptoms (EDS), and ≥15 eosinophils per high-power field (eos / hpf) in the esophagus after exclusion of other disorders with eosinophilia (1). In addition to the typical symptoms, they may have atypical and infrequent symptoms, among which is CC (2).
CC as the main symptom of EoE, associated or not with other EDS has been poorly studied and is not characterized. For this reason, the objective of this study is, research the frequency of CC as an atypical symptom and to investigate epidemiological, demographic, clinical, and endoscopic-histological and allergic characteristics, these co-morbidities, adherence to treatment and evolution.
Results
(Table 1 and 2)
Discussion
Atypical symptoms have also been described in EoE, although those are less frequent. Some of them are aerodigestive as CC (2,3).
In a study on the prevalence of extraesophageal symptoms in patients with EoE, it detets CC in 7–46% (4). It is rare but it can happen (2) that the main symptom of EoE is CC (5.1% de our patients), with the disadvantage that it is underdiagnosed, or its diagnosis is delayed of EoE. In other study son recurrent croup in children, thank you 7.3% were found to suffer from EoE.
We had not found studies which had evaluated the characteristics of the patients’ CC with EoE. There is lower or no evidence on the characteristics of this atypical symptom. Instead, we have observed that cough in EoE triggering during day (worsening or starting during or after food intakes)
As CC may be caused by an underlying EoE or merely coexistence with other diseases. We have carried out the differential diagnosis of CC requesting several complementary tests (Table 2). Most of the studies on EoE and CC have performed in children (5,6), whereas in our serie, the children are only 10%. Therefore, it is the first time that it has been studied CC, and its characteristics in adults with EoE. Excluding symptoms, rest of the characteristics are like other patients with typical EoE symptoms. (1).
Almost half of de our patients had a fibrostenotic endoscopic phenotype, compatible with a long evolution of the disease that can lead to oesophageal structural and functional alterations (1) and provoke serious complications (15% of our patients). CC could be influence as the main symptom of EoE in the diagnostic delay, and we forced us to carry out the differential diagnosis with respiratory diseases.
We highlight the good adherence to PPIs drugs of our patients, probably because they are eager to find a remedy for their CC.
CC improved in all patients who did treatment with PPIs dugs, but it only completely disappeared in the patients with EoE in remission. In subsequent reviews, several patients have acknowledged the reappearance of the cough upon cessation of adherence to treatment and its disappearance within three months of performing it again.
This study has its limitations, we present data from an Allergology Service, so it is possible that the results do not coincide with other settings. One strength would be that it is a prospective study that characterise CC secondary to EoE.
In conclusion, despite the frequency of the CC in EoE as a major symptom is low, the doctors should consider EoE in the differential diagnosis of CC in children and adults. Above all if it is diurnal, in relation with food intakes to avoid delays in diagnosis and treatment which can triggering complications that they reduce in the quality of life of patients
References
1. Dellon ES, Liacouras CA, Molina-Infante J, Furuta GT, Spergel JM, Zevit N et al. Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology. 2018;155(4):1022–33 e10.
2. Kumar S, Choi S, Gupta SK. Eosinophilic Esophagitis-A Primer for Otolaryngologists. JAMA Otolaryngol Head Neck Surg 2019; 145 (4): 373-80.
3. Ballart MJ, Monrroy H, Iruretagoyena M, Parada A, Torres J, Espino A. Diagnosis, and management of eosinophilic esophagitis]. Rev Med Chil. 2020;148(6):831-841.
4. Rubinstein E, Rosen RL. Respiratory symptoms associated with eosinophilic esophagitis. Pediatr Pulmonol. 2018;53(11):1587-1591.
5. Duval M, Tarasidis G, Grimmer JF, Muntz HR, Park AH, Smith M, et al. Role of operative airway evaluation in children with recurrent croup: a retrospective cohort study. Clin Otolaryngol. 2015;40(3):227-33.
6. Hill CA, Ramakrishna J, Fracchia MS, Sternberg D, Ojha S, Infusino S, et al.Prevalence of eosinophilic esophagitis in children with refractory aerodigestive symptoms. JAMA Otolaryngol Head Neck Surg. 2013;139(9):903-6.
Key words: Esophagitis; eosinophils; inflammation; food allergy
Words number : 590
Funding information : This work has not been funded by anything, or by anyone
Acknowledgment : None
Conflict Interest : None of the authors of this work have a conflict of interest.