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    "titulo" => "Occupational Allergic Respiratory Disease and Eosinophilic Esophagitis by Wheat Flour in a Baker"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Wheat can cause both immediate and delayed reactions&#46; Immediate&#44; IgE-mediated reactions may be triggered&#44; after eating foods that contain this cereal&#44; or by inhalation of wheat flour &#40;WF&#41;&#44; as in baker&#39;s asthma &#40;BA&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> The delayed reactions are not IgE-mediated&#44; cause digestive symptoms&#44; as it happens in eosinophilic esophagitis &#40;EoE&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe a 49-year-old man who worked as a baker for 30 years&#46; He was referred to the allergology clinic by nasoocular itching&#44; watery eyes&#44; sneezing&#44; runny nose&#44; nasal obstruction&#44; dry cough and dyspnea&#46; His symptoms began after handling WF in his workplace&#44; improving during weekends or holidays&#46; He was treated with antihistamines and inhaled budesonide &#40;400<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day&#41;&#44; with good control for 10 years&#46; In the last 5 years he worsened&#44; needing to increase the dose of inhaled corticosteroids and adding salbutamol as rescue medication&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Simultaneously&#44; he began with symptoms of esophageal dysfunction &#40;SED&#41; &#40;dysphagia&#44; chocking and heartburn&#41;&#46; He was treated with omeprazole&#44; 40 daily&#47;20 years&#44; with improvement and resolution of his symptoms but was never studied by a gastroenterologist&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Allergy study&#44; skin prick tests &#40;SPT&#41; and specific IgE &#40;sIgE&#41; were negative &#40;mean SPT wheal &#60;3<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mm and sIg E &#60;0&#46;35<span class="elsevierStyleHsp" style=""></span>kU&#47;L&#41; to pollens &#40;grass&#44; <span class="elsevierStyleItalic">Olea europaea</span> and <span class="elsevierStyleItalic">Salsola kali</span>&#41;&#44; mites &#40;<span class="elsevierStyleItalic">D&#46; pteronyssinus</span>&#44; <span class="elsevierStyleItalic">D&#46; farinae</span> and <span class="elsevierStyleItalic">L&#46; detructor</span>&#41;&#44; molds &#40;<span class="elsevierStyleItalic">A&#46; alternata</span>&#44; <span class="elsevierStyleItalic">Cladosporum</span> and <span class="elsevierStyleItalic">Aspergyllus</span>&#41; and animal dander &#40;cat&#44; dog&#41;&#46; SPTs were positive with WF commercial extract &#40;ALK-Abell&#243;&#44; Madrid&#41; and in prick by prick test&#46; Total serum IgE&#58; 135<span class="elsevierStyleHsp" style=""></span>kU&#47;L&#46; and specific IgE to WF 2&#46;5<span class="elsevierStyleHsp" style=""></span>kU&#47;L&#46; Specific IgE to gluten&#44; r-&#969;-5-gliadin&#44; &#945;-amylase and Tri a 14 were all negative &#40;ImmunoCAP&#44; ThermoFisher&#44; Uppsala&#44; Sweden&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The basal spirometry was normal&#46; The methacholine bronchial test with an abbreviated method<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> was positive &#40;PD20&#58; 0&#46;20<span class="elsevierStyleHsp" style=""></span>mg cumulative dose&#41; while he was working&#44; but&#44; after 3 months of sick leave&#44; it was negative&#46; Chest X-ray was normal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A specific bronchial test was carried out with WF&#44; tipping it from one tray into another for 15<span class="elsevierStyleHsp" style=""></span>min&#46; Spirometries were performed at baseline and at 2&#44; 5&#44; 10&#44; 15&#44; 20&#44; 30&#44; 45 and 60<span class="elsevierStyleHsp" style=""></span>min after the exposure to WF&#46; Peak expiratory flow was measured at baseline and over a period of 24<span class="elsevierStyleHsp" style=""></span>h &#40;respecting sleeping patterns&#41;&#46; A 23&#37; fall in FEV1 was observed 15<span class="elsevierStyleHsp" style=""></span>min after exposure to WF&#46; The patient did not have any late reaction&#46; A bronchial control test with saline carried out on the previous day was negative&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A sodium dodecyl sulphate polyacrylamide gel electrophoresis immunoblot analysis with WF extract was performed using the Laemmle method&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> A specific binding was detected between 37 and 70<span class="elsevierStyleHsp" style=""></span>kDa&#46; Glutenins in within the range of these molecular weights&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Endoscopy &#40;E&#41;1&#58; without taking omeprazole&#44; during a working period and ingesting WF&#46; E2&#58; working&#44; ingesting WF and omeprazole&#59; E3&#58; without ingesting neither WF nor omeprazole and without exposure &#40;sick leave&#41;&#59; E4&#58; without omeprazole&#44; without exposure but with ingestion of WF&#59; E5&#58; without omeprazole&#44; working&#44; and without ingesting WF&#46; E6&#58; without omeprazole&#44; without exposure and ingesting a gluten-free diet &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The diagnosis was made according to the updated international consensus diagnostic criteria for EoE&#58; AGREE conference&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Remission is confirmed &#60;15<span class="elsevierStyleHsp" style=""></span>eos&#47;cga &#40;total and partial remission&#58; &#60;5 and 5&#8211;14<span class="elsevierStyleHsp" style=""></span>eos&#47;hpf&#44; respectively&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In E1&#44; &#62;15<span class="elsevierStyleHsp" style=""></span>eosinophils&#47;hpf were detected in the esophagus and &#60;3<span class="elsevierStyleHsp" style=""></span>eosinophils&#47;hpf in the stomach and duodenum&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patient&#39;s responses to omeprazole&#44; to a wheat-free diet&#44; and to the environmental exposure to WF&#46; The avoidance of WF&#44; both by the digestive and the bronchial route&#44; were capable to solve the EoE&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient was diagnosed with occupational allergic respiratory disease &#40;OARD&#41;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> and occupational EoE<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> caused by WF&#46; The evolution of the patient has been very good&#59; after being retired from his job and on a wheat-free diet&#44; he is asymptomatic&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">EoE and OARD are frequently found as comorbidities along with other atopic manifestations&#46; These two conditions have similar T helper type 2 responses-driven pathophysiology and share common management strategies<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#59; this case is a clear example of the multiorganic clinical manifestations of atopy&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">EoE experts have so far questioned whether this disease could be caused by the inhalation of allergens&#46; The case described suggests that the answer would be affirmative&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> The small number of reported cases caused by aeroallergens could be justified because&#44; until now&#44; some doctors who treat atopic patients have little experience in the diagnosis and management of EoE&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In Spanish bakers&#44; sensitization to grass pollen and to rTria 14 is frequent&#44; however&#44; our patient is only sensitized to WF&#46; The positive methacholine test&#44; confirms that patient has bronchial asthma and the positive specific bronchial challenge test indicates that it is an OARD by WF&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">OARD to wheat proteins is very frequent and its prevalence does not seem to be declining&#46; The researchers on BA point out the strong limitations of its diagnosis and treatment&#59; they think that the isolation and characterization of cereal allergens associated with BA&#44; particularly from WF would allow us to better define major and minor allergens&#44; what would help to provide an adequate diagnostic panel of molecular markers&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The EoE responded to omeprazole<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> but the patient had to follow a gluten-free cereal exclusion diet and to avoid WF inhalation simultaneously to achieve remission&#46; Neither diet nor being off-work separately were sufficient for the resolution of the EoE&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In patients with SED&#44; it is important to study if they have EoE or gastroesophageal reflux disease or both&#44; because can worsen asthma&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We present an unusual case in which WF triggers EoE and an occupational OARD in the same patient&#44; in which the inhalation of WF triggered the two diseases and EoE is caused by the oral and inhalation routes&#46; When we diagnose an OARD&#44; we should ask the patient for SED&#44; since an early diagnosis and treatment will improve the prognosis and the quality of life of these patients&#46;</p></span>"
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Scientific Letter
Occupational Allergic Respiratory Disease and Eosinophilic Esophagitis by Wheat Flour in a Baker
Enfermedad respiratoria alérgica ocupacional y esofagitis eosinófila por harina de trigo en un panadero
Elisa Gómez Torrijos
Corresponding author
egomezt.cr@gmail.com

Corresponding author.
, Lucia Moreno Lozano, Rosa Garcia Rodriguez
Allergy Section, Hospital General Universitario, Ciudad Real, Spain
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      "titulo" => "Need for Portable Oxygen Titration Using 6-Minute Walk Tests"
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          "autoresLista" => "Tamara Lourido-Cebreiro, Francisco J&#46; Gonz&#225;lez-Barcala, Jos&#233; Manuel &#193;lvarez-Doba&#241;o, Tara Pereiro-Brea, Romina Abelleira-Paris, Luis Vald&#233;s"
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    "titulo" => "Occupational Allergic Respiratory Disease and Eosinophilic Esophagitis by Wheat Flour in a Baker"
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        "autoresLista" => "Elisa G&#243;mez Torrijos, Lucia Moreno Lozano, Rosa Garcia Rodriguez"
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        "titulo" => "Enfermedad respiratoria al&#233;rgica ocupacional y esofagitis eosin&#243;fila por harina de trigo en un panadero"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Wheat can cause both immediate and delayed reactions&#46; Immediate&#44; IgE-mediated reactions may be triggered&#44; after eating foods that contain this cereal&#44; or by inhalation of wheat flour &#40;WF&#41;&#44; as in baker&#39;s asthma &#40;BA&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> The delayed reactions are not IgE-mediated&#44; cause digestive symptoms&#44; as it happens in eosinophilic esophagitis &#40;EoE&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe a 49-year-old man who worked as a baker for 30 years&#46; He was referred to the allergology clinic by nasoocular itching&#44; watery eyes&#44; sneezing&#44; runny nose&#44; nasal obstruction&#44; dry cough and dyspnea&#46; His symptoms began after handling WF in his workplace&#44; improving during weekends or holidays&#46; He was treated with antihistamines and inhaled budesonide &#40;400<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day&#41;&#44; with good control for 10 years&#46; In the last 5 years he worsened&#44; needing to increase the dose of inhaled corticosteroids and adding salbutamol as rescue medication&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Simultaneously&#44; he began with symptoms of esophageal dysfunction &#40;SED&#41; &#40;dysphagia&#44; chocking and heartburn&#41;&#46; He was treated with omeprazole&#44; 40 daily&#47;20 years&#44; with improvement and resolution of his symptoms but was never studied by a gastroenterologist&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Allergy study&#44; skin prick tests &#40;SPT&#41; and specific IgE &#40;sIgE&#41; were negative &#40;mean SPT wheal &#60;3<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mm and sIg E &#60;0&#46;35<span class="elsevierStyleHsp" style=""></span>kU&#47;L&#41; to pollens &#40;grass&#44; <span class="elsevierStyleItalic">Olea europaea</span> and <span class="elsevierStyleItalic">Salsola kali</span>&#41;&#44; mites &#40;<span class="elsevierStyleItalic">D&#46; pteronyssinus</span>&#44; <span class="elsevierStyleItalic">D&#46; farinae</span> and <span class="elsevierStyleItalic">L&#46; detructor</span>&#41;&#44; molds &#40;<span class="elsevierStyleItalic">A&#46; alternata</span>&#44; <span class="elsevierStyleItalic">Cladosporum</span> and <span class="elsevierStyleItalic">Aspergyllus</span>&#41; and animal dander &#40;cat&#44; dog&#41;&#46; SPTs were positive with WF commercial extract &#40;ALK-Abell&#243;&#44; Madrid&#41; and in prick by prick test&#46; Total serum IgE&#58; 135<span class="elsevierStyleHsp" style=""></span>kU&#47;L&#46; and specific IgE to WF 2&#46;5<span class="elsevierStyleHsp" style=""></span>kU&#47;L&#46; Specific IgE to gluten&#44; r-&#969;-5-gliadin&#44; &#945;-amylase and Tri a 14 were all negative &#40;ImmunoCAP&#44; ThermoFisher&#44; Uppsala&#44; Sweden&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The basal spirometry was normal&#46; The methacholine bronchial test with an abbreviated method<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> was positive &#40;PD20&#58; 0&#46;20<span class="elsevierStyleHsp" style=""></span>mg cumulative dose&#41; while he was working&#44; but&#44; after 3 months of sick leave&#44; it was negative&#46; Chest X-ray was normal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A specific bronchial test was carried out with WF&#44; tipping it from one tray into another for 15<span class="elsevierStyleHsp" style=""></span>min&#46; Spirometries were performed at baseline and at 2&#44; 5&#44; 10&#44; 15&#44; 20&#44; 30&#44; 45 and 60<span class="elsevierStyleHsp" style=""></span>min after the exposure to WF&#46; Peak expiratory flow was measured at baseline and over a period of 24<span class="elsevierStyleHsp" style=""></span>h &#40;respecting sleeping patterns&#41;&#46; A 23&#37; fall in FEV1 was observed 15<span class="elsevierStyleHsp" style=""></span>min after exposure to WF&#46; The patient did not have any late reaction&#46; A bronchial control test with saline carried out on the previous day was negative&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A sodium dodecyl sulphate polyacrylamide gel electrophoresis immunoblot analysis with WF extract was performed using the Laemmle method&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> A specific binding was detected between 37 and 70<span class="elsevierStyleHsp" style=""></span>kDa&#46; Glutenins in within the range of these molecular weights&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Endoscopy &#40;E&#41;1&#58; without taking omeprazole&#44; during a working period and ingesting WF&#46; E2&#58; working&#44; ingesting WF and omeprazole&#59; E3&#58; without ingesting neither WF nor omeprazole and without exposure &#40;sick leave&#41;&#59; E4&#58; without omeprazole&#44; without exposure but with ingestion of WF&#59; E5&#58; without omeprazole&#44; working&#44; and without ingesting WF&#46; E6&#58; without omeprazole&#44; without exposure and ingesting a gluten-free diet &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The diagnosis was made according to the updated international consensus diagnostic criteria for EoE&#58; AGREE conference&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Remission is confirmed &#60;15<span class="elsevierStyleHsp" style=""></span>eos&#47;cga &#40;total and partial remission&#58; &#60;5 and 5&#8211;14<span class="elsevierStyleHsp" style=""></span>eos&#47;hpf&#44; respectively&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In E1&#44; &#62;15<span class="elsevierStyleHsp" style=""></span>eosinophils&#47;hpf were detected in the esophagus and &#60;3<span class="elsevierStyleHsp" style=""></span>eosinophils&#47;hpf in the stomach and duodenum&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patient&#39;s responses to omeprazole&#44; to a wheat-free diet&#44; and to the environmental exposure to WF&#46; The avoidance of WF&#44; both by the digestive and the bronchial route&#44; were capable to solve the EoE&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient was diagnosed with occupational allergic respiratory disease &#40;OARD&#41;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> and occupational EoE<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> caused by WF&#46; The evolution of the patient has been very good&#59; after being retired from his job and on a wheat-free diet&#44; he is asymptomatic&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">EoE and OARD are frequently found as comorbidities along with other atopic manifestations&#46; These two conditions have similar T helper type 2 responses-driven pathophysiology and share common management strategies<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#59; this case is a clear example of the multiorganic clinical manifestations of atopy&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">EoE experts have so far questioned whether this disease could be caused by the inhalation of allergens&#46; The case described suggests that the answer would be affirmative&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> The small number of reported cases caused by aeroallergens could be justified because&#44; until now&#44; some doctors who treat atopic patients have little experience in the diagnosis and management of EoE&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In Spanish bakers&#44; sensitization to grass pollen and to rTria 14 is frequent&#44; however&#44; our patient is only sensitized to WF&#46; The positive methacholine test&#44; confirms that patient has bronchial asthma and the positive specific bronchial challenge test indicates that it is an OARD by WF&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">OARD to wheat proteins is very frequent and its prevalence does not seem to be declining&#46; The researchers on BA point out the strong limitations of its diagnosis and treatment&#59; they think that the isolation and characterization of cereal allergens associated with BA&#44; particularly from WF would allow us to better define major and minor allergens&#44; what would help to provide an adequate diagnostic panel of molecular markers&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The EoE responded to omeprazole<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> but the patient had to follow a gluten-free cereal exclusion diet and to avoid WF inhalation simultaneously to achieve remission&#46; Neither diet nor being off-work separately were sufficient for the resolution of the EoE&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In patients with SED&#44; it is important to study if they have EoE or gastroesophageal reflux disease or both&#44; because can worsen asthma&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We present an unusual case in which WF triggers EoE and an occupational OARD in the same patient&#44; in which the inhalation of WF triggered the two diseases and EoE is caused by the oral and inhalation routes&#46; When we diagnose an OARD&#44; we should ask the patient for SED&#44; since an early diagnosis and treatment will improve the prognosis and the quality of life of these patients&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Omeprazole&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Eos&#47;hpf in the 3 sections of the esophagus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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ISSN: 15792129
Original language: English
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