Outcomes of Serum Food-Specific Immunoglobulin G 4 to Guide Elimination Diet in Patients With Eosinophilic Esophagitis

Amanda Huoy Wen Lim; Benjamin Ngoi; Griffith B Perkins; Stephanie Wong; Gail Whitelock; Plinio Hurtado; Andrew Ruszkiewicz; Thanh-Thao Adriana Le; Pravin Hissaria; Nam Quoc Nguyen

doi:10.14309/ajg.0000000000002678

Outcomes of Serum Food-Specific Immunoglobulin G 4 to Guide Elimination Diet in Patients With Eosinophilic Esophagitis

Am J Gastroenterol. 2024 Mar 18. doi: 10.14309/ajg.0000000000002678. Online ahead of print.

Authors

Amanda Huoy Wen Lim^{1

2}, Benjamin Ngoi², Griffith B Perkins^{2

3}, Stephanie Wong^{1

2}, Gail Whitelock⁴, Plinio Hurtado^{2

3}, Andrew Ruszkiewicz^{2

5

6}, Thanh-Thao Adriana Le⁷, Pravin Hissaria^{2

7}, Nam Quoc Nguyen^{1

2}

Affiliations

¹ Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia.
² Adelaide Medical School, University of Adelaide, Adelaide, Australia.
³ Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia.
⁴ Nutrition and Dietetics, Royal Adelaide Hospital, Adelaide, Australia.
⁵ Department of Surgical Pathology, SA Pathology, Adelaide, Australia.
⁶ Centre of Cancer Biology, University of South Australia, Adelaide, Australia.
⁷ Department of Immunology, Royal Adelaide Hospital, Adelaide, Australia .

PMID: 38299582
DOI: 10.14309/ajg.0000000000002678

Abstract

Introduction: Eosinophilic esophagitis (EoE) is associated with atopy; however, recent studies have identified an association with food-specific immunoglobulin G 4 (FS-IgG 4 ) rather than immunoglobulin E antibodies. This study aimed to evaluate the role of serum FS-IgG 4 in guiding an elimination diet and its outcomes.

Methods: Patients with and without EoE were enrolled in a prospective, controlled, single tertiary center trial. Serum FS-IgG 4 titers, esophageal eosinophil counts, and dysphagia symptom questionnaire scores were assessed, and participants with elevated FS-IgG 4 (ImmunoCAP, cutoff of 10 mgA/L) commenced 6-week targeted elimination diet. Repeat serum FS-IgG 4 and endoscopic and histologic examination were performed at 6-week follow-up.

Results: Twenty-two patients with active EoE and 13 controls were recruited. Serum FS-IgG 4 to milk, wheat, soy, eggs, and nuts was significantly higher in EoE ( P = 0.0002, P = 0.002, P = 0.003, P = 0.012, and P < 0.001, respectively). Elevated serum FS-IgG 4 to 1 or more food groups (median 2) was identified in 21/22 (95.4%) patients with EoE; 20/21 underwent 6-week dietary elimination. Median reductions in dysphagia symptom questionnaire score and EoE endoscopic reference score after elimination were 8 ( P = 0.0007) and 1 ( P = 0.002), respectively. Nine (45%) patients had histological remission (<15 eosinophils per high-power field). Fall in median esophageal eosinophil count was not statistically significant (50 vs 23; P = 0.068). Serum FS-IgG 4 did not decline by 6-week follow-up.

Discussion: Serum FS-IgG 4 to milk, wheat, soy, egg, and nuts was present at higher levels in EoE, with targeted elimination resulting in 45% histologic remission rate. Serum FS-IgG 4 has potential as a noninvasive biomarker in EoE. When successful, FS-IgG 4 -led elimination diet can negate need for medications and be viewed more favorably by patients because of its smaller endoscopic burden compared with empirical elimination diets.