<div>Additional Features of Food Induced Immediate Reaction in the Esophagus
(FIRE) in a Series of Adult Patients with Eosinophilic Esophagitis</div><div>To the Editor</div><div>Eosinophilic esophagitis (EoE) is a chronic disease characterized
clinically by symptoms related to esophageal dysfunction and
histologically by eosinophil predominant inflammation. The predominant
symptom in adults with active EoE is solid food dysphagia due to the
high incidence of esophageal stricture formation. A quantitative tool
has been developed to characterize the nature of these symptoms (1).
Most typically patients complain of food going down slowly, food getting
stuck and pain. These symptoms are most likely to occur during the
passage of dense solid foods such as meats, bread and rice.</div><div>Recently a phenomenon with a different symptom referred to as FIRE (food
induced immediate reaction in the esophagus) has been described in
adults with EoE. (2). Patients with eosinophilic esophagitis describe
these esophageal symptoms as distinct from dysphagia. The symptoms
typically occur after the food has been swallowed with rapid onset
esophageal discomfort often described as tightening or pressure but
without the sense of dysphagia. A large series of Swiss patients with
eosinophilic esophagitis were queried via a form mailed to their homes
or in clinics concerning symptoms related an immediate reaction in the
esophagus distinct from dysphagia (2). A significant portion (49%)
reported some form of esophageal discomfort related to eating. Although
certain subject characteristics in this study such as younger age of
onset of EoE and higher prevalence of allergies was noted, detailed
clinical information on each subject was not available for review. Here
in we described a series of patients with biopsy proven eosinophilic
esophagitis who describe characteristic symptoms of FIRE following a
specific food ingestion. For each selected FIRE patient a detailed chart
review was conducted characterizing their demographics and EoE history
(Table 1) as well as characteristics of their FIRE profile (Table 2). A
number of features were noted in this group of 8 EoE patients as a
previously unrecognized symptom complex. The onset of symptoms most
often occurred within 1-60 minutes (median 3.5 minutes) after ingestion
of the food. The duration of symptoms lasted from &lt;10 minutes
to &gt; 6 hours (median 120 minutes). Among the patients the
description of discomfort was often similar consisting of a tightening
or pressure in the mid sternum. The most common foods inducing symptoms
were beans, melon and beer. The symptoms were significant enough that
patients attempted to subsequently avoid these foods. All patients were
able to distinguish between symptoms related to their pollen food
allergy syndrome and FIRE.</div><div>The exact mechanism of this esophageal discomfort has not been
elucidated. It appears distinct from pollen food allergy syndrome. It
also appears different from EoE as uncommon foods such as banana, melon
and avocado were capable of invoking symptoms, notably foods more
commonly associated with oral allergy syndrome. However the strong
association with atopy, the rapid onset of symptoms and symptoms
distinct from dysphagia suggest a local possibly immunologic factor
causing an immediate esophageal mucosal response. A careful history of
FIRE symptoms should be part of the routine evaluation of patients with
eosinophilic esophagitis. Further investigations will be required to
help better understand the frequency and mechanism of this newly
described phenomenon.</div><div>Conflicts of Interest</div><div>MH no conflicts, AS no conflicts</div><div>Mark Holbreich M.D.</div><div>Alex Straumann M.D.</div><div>1. Schoepfer AM, Straumann A, Panczak R, et al. Development and
validation of a symptom-based activity index for adults with
eosinophilic esophagitis. Gastroenterology 2014;147:1255–1266.</div><div>2. Biedermann, L, Holbreich, M, Atkins, D, et al. Food‐induced immediate
response of the esophagus—A newly identified syndrome in patients with
eosinophilic esophagitis. <i>Allergy</i> . 2020; 00: 1– 9.</div><div>Corresponding author</div><div>Mark Holbreich M.D.</div><div>Allergy and Asthma Consultants</div><div>Indianapolis IN USA</div><div>mholbreich@comcast.net</div>