D1.178 - FIRE Starters: Investigating Food Induced Immediate Esophageal Response in Eosinophilic Esophagitis

Food induced-immediate response of the esophagus (FIRE) is a newly described syndrome, commonly observed in eosinophilic esophagitis (EoE) patients. It implies the rapid and recurrent development of unpleasant and painful retrosternal sensation or choking after consuming triggering food, distinct from classical dysphagia. Current data on FIRE is limited to a survey based on expert opinions and patient responses along with case reports. Here, we present an 18-year-old male with symptoms consistent with FIRE characteristics.

The patient presented with a 3-year history of recurrent retrosternal pain and choking occurring 5 minutes after consuming raw fruits and vegetables. He was diagnosed with EoE one year prior to referral to our clinic and achieved clinical and histological remission following PPI treatment. However, the acute symptoms triggered by raw plant-based foods persisted despite the resolution of EoE. He also had allergic rhinitis with sensitization to ambrosia pollen.

The allergy work-up revealed specific IgE positivity for Amb a 1 and several profillins: Phl p 12, Bet v 2, Pho d 2, Mer a 1, Cuc m 2, Hev b 8, using ALEX MADx. The results were consistent with the patient's complaints, considering his tolerance of cooked foods. The patient excluded the offending foods from the diet.

    Reports of FIRE in the literature are scarce, comprising 103 adult and 2 pediatric patients. The pathogenesis is unclear to date. An allergic response of the esophageal mucosa seems to be involved due to the rapid onset and also to the common association to other allergic comorbidities such as allergic rhinitis. Skin prick test positivity to suspected foods was observed in one pediatric case and 50% of adult cases with FIRE supporting the involvement of an IgE-mediated mechanism.

Although FIRE is still a new and under-recognized condition, through its unusual, yet loud symptoms it could serve as an early indicator for EoE investigation. Furthermore, it may guide the therapeutic diet through easy identification of triggering foods. This case emphasizes the need for allergy testing in identifying a tailored therapeutic strategy. Further research is required to understand FIRE mechanisms and epidemiology.