Delayed hypersensitivity reaction to orodispersible budesonide in a case with eosinophilic esophagitis
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CASE REPORT
Delayed hypersensitivity reaction to orodispersible budesonide in a case with eosinophilic esophagitis Caroline Michèle Andrist1, Lukas Jörg1* , Thomas Greuter2, Anna Gschwend1, Alex Straumann3 and Arthur Helbling1
Abstract Background: Eosinophilic esophagitis (EoE) is a chronic inflammatory disease that has been known since the early 1990s. Swallowed topical corticosteroids (STC) belong to the therapeutic cornerstones. We describe a delayed hypersensitivity reaction to Jorveza®, a newly developed orodispersible budesonide tablet licensed for the treatment of eosinophilic esophagitis. Case presentation: A 32-year-old Caucasian woman with EoE was newly treated with Jorveza®. Hours after the first intake, she felt a “strange pruritus” in the throat. This sensation worsened with each subsequent intake. On day 4 she developed oral mucosal symptoms (paresthesia of the tongue, sore and an itchy throat). Intraoral, throat and facial swellings, but no systemic reaction were observed. Patch testing using two commercial test series as well as the orodispersible budesonide tablet revealed a strong sensitization, proving a T cell mediated allergy to budesonide. Conclusions: Orodispersible budesonide is increasingly prescribed for the treatment of eosinophilic esophagitis. The development of oropharyngeal symptoms after initiating should alert the treating physician to the possibility of a hypersensitivity reaction. Keywords: Orodispersible budesonide, Delayed hypersensitivity reaction, Eosinophilic esophagitis, Jorveza, Exanthema Background Eosinophilic esophagitis (EoE) is an esophagealrestricted, chronic inflammatory disease often associated with atopy. The prevalence of EoE is dramatically increasing and has currently reached values about 43 individuals per 100,000 inhabitants [1]. EoE occurs in people of all ages [2], but is more prevalent among men and more common in Caucasians than in Africans [3]. Current therapeutic opinions are built on the three Ds: *Correspondence: [email protected] 1 Division of Allergology, Department of Rheumatology, Immunology, and Allergology, Inselspital, Bern University Hospital, 3010 Bern, Switzerland Full list of author information is available at the end of the article
Drugs (swallowed topical corticosteroids [STC], protonpump inhibitors [PPIs] and biologics), Dietary restrictions to avoid alimentary antigens and, if the disease has led to the formation of strictures in advanced stages, endoscopic Dilation [4]. The effectiveness of STCs as induction treatment for acute EoE is well documented by a multitude of randomized controlled trials [5, 6]. The effect can be explained by a reduction of inflammatory cells, which leads to less fibrosis and also reverses IL13induced pathways [7]. Among STCs, fluticasone and budesonide are the most commonly used in the management of EoE [7]. Both are topically effective but have to be swallowed for the treatment. In January 2018, the orodispersible budesonide tablet Jorveza® (budesonide, Dr. Falk Pharma GmbH,
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