montelukast and Esophageal-Stenosis

An otherwise healthy 20-year-old man was admitted to our hospital with obstruction of the oesophagus by a bolus after eating a chicken meal. These symptoms continued over the past 12 years and required multiple interventions at different hospitals. There was no history of any other previous illness and both the physical examination and routine laboratory tests were unremarkable.. Esophagogastroduodenoscopy (EGD) revealed segmental circular trachea-like constrictions of the esophagus and two stenoses at 35 cm and 40 cm. Histopathology of several biopsies favored the diagnosis of eosinophilic esophagitis.. After initial balloon dilatation and dilatation with a Savary bougie the patient was put on systemic steroids and montelukast (a leukotriene receptor antagonist). The symptoms subsequently disappeared.. Eosinophilic esophagitis, a unique form of esophageal inflammatory disease, consists of dense eosinophilic infiltration of the epithelium and is associated with various macroscopic findings, such as the rare but striking circular trachea-like constrictions, nodules, plaques and other forms of constriction of the esophagus. Several lines of evidence favor an allergic cause. The leading symptom is recurrent dysphagia after solid foods, sometimes accompanied by heart-burn. Medical treatment consists of topical or systemic administration of steroids and/or montelukast. A history of chronic dysphagia after eating solid food, combined with endoscopic findings atypical for reflux disease is highly suspicious of eosinophilic esophagitis in the differential diagnosis of gastroesophageal reflux disease in adults.

Topics: Acetates; Adult; Biopsy; Catheterization; Cyclopropanes; Deglutition Disorders; Diagnosis, Differential; Dilatation; Drug Therapy, Combination; Endoscopy, Digestive System; Eosinophilia; Esophageal Stenosis; Esophagitis; Esophagus; Glucocorticoids; Humans; Leukotriene Antagonists; Male; Prednisolone; Quinolines; Sulfides

Eosinophilic gastroenteritis (EG) is an uncommon entity of which the pathogenesis is unclear. As no controlled treatment trials exist, treatment of EG remains largely empiric. Limited results have been achieved with oral cromolyn, ketotifen, and other antihistamines. Oral corticosteroids are effective, but long-term use is complicated by side effects including growth retardation, diabetes, and osteoporosis.. We sought to determine whether treatment with montelukast would improve symptoms and decrease both peripheral blood and tissue eosinophilia (TE) in a patients with steroid-dependent EG for 20 years complicated by esophageal stricture.. In an unblinded, n = 1 trial, we treated the patient for 5 months with montelukast (20 to 30 mg daily) while his baseline dose of prednisone (10 mg daily) was continued. Complete blood counts and symptoms were monitored weekly. Esophageal biopsies were obtained before and after 5 months of therapy with montelukast. After the posttreatment biopsy was obtained, montelukast was discontinued. Outcome measures included patient symptoms and peripheral and tissue eosinophil counts.. During treatment with montelukast, the mean peripheral blood eosinophil count fell from 5,064 cells/microL (average 28 determinations over 20 years; range 1,408 to 12,500 cells/microL) to 1,195 cells/microL (average 14 determinations over 16 weeks; range 556 to 2,193 cells/microL), a 76% reduction. The corresponding TE as calculated from esophageal biopsies was 31 eosinophils/high power field before and 70 eosinophils/high power field after treatment. The patient noted no appreciable improvement in esophageal symptoms.. Montelukast dramatically reduced peripheral blood eosinophilia, but did not affect TE or symptoms in this patient with severe, long-standing EG complicated by esophageal stricture.

Topics: Acetates; Adult; Cyclopropanes; Eosinophilia; Eosinophils; Esophageal Stenosis; Gastroenteritis; Humans; Leukocyte Count; Leukotriene Antagonists; Male; Quinolines; Sulfides; Treatment Outcome