Development of eosinophilic esophagitis during wheat oral immunotherapy in children: a retrospective cohort analysis

Oral immunotherapy (OIT) is an emerging treatment for IgE-mediated food allergy, but eosinophilic esophagitis (EoE) has been reported as a potential complication, especially with milk and egg. Data on wheat OIT are limited. This study examined the incidence, course, and outcomes of EoE in children undergoing wheat OIT.

We retrospectively reviewed 79 children with confirmed IgE-mediated wheat allergy treated with OIT between 2020 and 2023 at two tertiary centers in Iran. Patients with suspected EoE underwent endoscopy with histopathology. Diagnosis required ≥15 eosinophils/high-power field. Management included wheat elimination and proton pump inhibitors (PPIs) ± topical corticosteroids.

Eight of 79 patients (10.1%) developed EoE. Seven became symptomatic during up-dosing or early maintenance; one asymptomatic patient was diagnosed at parental request. Histopathology confirmed 18-110 eosinophils/HPF. All symptomatic cases improved after OIT discontinuation and medical therapy. No severe anaphylaxis occurred. Follow-up endoscopy was limited by patient refusal.

EoE occurred in 10% of children during wheat OIT, mainly in the up-dosing phase. While symptoms resolved with treatment and cessation, distinguishing transient OIT-induced eosinophilia from persistent EoE remains critical. Prospective studies with pre- and post-OIT endoscopy are needed to guide monitoring and management.