Although the standard of care for cow's milk (CM)
allergy is strict food avoidance, oral
immunotherapy (OIT) is being widely investigated as an alternative management option in certain cases. Immediate adverse reactions to OIT have been described, but its long-term effects are much less often reported. We present the case of a girl diagnosed with
IgE-mediated CM
allergy that was proposed for our CM OIT protocol at the age of 3 years. The first sessions (dose escalation up to 5 ml) were well tolerated, however eight hours after her daily morning dose of 5 ml CM the child developed late episodes of
vomiting. No other symptoms, particularly immediately after CM ingestion, were reported. These episodes became progressively worse and on the third day she presented mild
dehydration and blood
eosinophilia. After OIT interruption, a progressive clinical improvement was observed. An esophageal endoscopy was performed, showing signs of
eosinophilic esophagitis (EoE) with peak 20 eosinophils/hpf.
After treatment with topical swallowed
fluticasone (500 mcg bid) and a CM-free diet for 4 months, the child was asymptomatic and endoscopy and biopsy findings were normal.The long-term effects of milk OIT are still in part unknown. We hypothesize that
eosinophilic esophagitis may have been a consequence of OIT in this case. The findings seem to indicate that
food allergy may play a role in the pathogenesis of esophageal
eosinophilia and stress the importance of a well programmed long-term follow-up of patients that have undergone milk OIT.