Thursday, July 5, 2012
Eosinophils (so called because they stain with eosin for microscopic observation) are one of the varieties of white cells that we possess in the blood. Eosinophilic esophagitis is an inflammatory reaction in the esophagus associated with an infiltration of these cells. It is only in recent years that the disease was discovered and is easily confused with the more common gastro-esohageal reflux (GERD) since the symptoms are similar. However, it does not respond to GERD treatments and the diagnosis can only be made by upper endoscopy performed by a specialist when biopsies are taken and the true nature of the problem is revealed. The literature on the subject indicates that the cause is unknown and treatment appears to be very unpredictable and unsatisfactory at the best. I had never heard of this disease until a parent called my office and asked whether I might be able to help her fourteen year old boy. Since my practice is based on the principles that I have outlined in this blog, I agreed to a consultation. I want to describe the case in some detail because I believe that it throws new light on this mystery. It is particularly important because this formidable disease is apparently becoming much more common and there are few clues indicated in the medical literature. The history in this case is astonishing because it almost certainly reveals that the underlying cause starts long before the diagnosis is made. Indeed, in this boy it was very much apparent that the seeds of the inflammatory reaction started in infancy. He had been exhaustively studied at a number of prestigious medical institutions and many treatments had been attempted without success. His sensitivity to pain was extreme and it was reported to me that in one hospital he had been “shredding his underwear because of the pain”. It was also stated that he had experienced anaphylaxis, although the details were not given. This is a dangerous reaction that can occur, for example, as a result of a bee sting. It is regarded as an extreme form of allergy. This is the medical history that I obtained from the parents. A pediatrician always starts asking questions beginning with the mother’s pregnancy and the patient’s early infancy. This boy had suffered a series of ear infections in infancy and PE tubes (the little plastic tubes inserted through the ear drum) were inserted at the age of 2 years. I was told that three procedures were performed because of technical difficulties. This is important because I learned from an experienced ear, nose and throat surgeon that PE tubes are placed, “not for drainage but to allow oxygen into the middle ear cavity”. This again implies that oxidative deficiency plays a vital part in the cause of these common ear infections in infants. He had experienced several episodes of cough and wheezing called asthmatic bronchitis. On specific questioning, I was told that he would cough in his sleep. We will see later why that was also of possible importance. On questioning about emotional reaction, I was told that he “wanted to be destructive” (post: Nov 8,2010). He would become very fatigued and fall asleep on the school bus. He was frequently irritable, had experienced “panic attacks”, frequent brief chest pains, severe abdominal pain, joint pains and stiffness, fits of depression and 3 to 5 headaches a week. He complained of difficulty in getting to sleep and would awaken frequently in the night. At the age of 8 years he had his first abdominal pain that was severe enough to consider appendicitis. It was initially diagnosed as Irritable Bowel Syndrome, but the diagnosis of Eosinophilic Esophagitis was finally made by endoscopy at the age of 11 years. Physical examination revealed that he had the heart signs strongly suggestive of mitral valve prolapse, a condition that is known to be associated with dysautonomia. This diagnosis was supported by abnormal knee reflexes. Heart rate was 54 beats per minute, unusually slow for a child, suggesting parasympathetic dominance(Post: June12,2011). His abdominal wall was extremely tense and even a slight touch made in the examination elicited extreme pain. To the uninformed observer this would suggest a neurotic over-reaction to stimulus, but oxidative dysfunction in the control mechanisms of the autonomic nervous system can cause exaggeration of the reaction to many different stimuli, including tactile input. Until the findings of the endoscopy, showing clearly that he had organic disease, this boy’s condition was considered to be psychosomatic, for all laboratory studies had been repeatedly normal. The finding in the endoscopy was considerted to exclude the brain as part of the disease. An unusual laboratory study (unusual because therapeutic use of nutrients is not an accepted general approach to any disease except the classic vitamin deficiencies considered to be of only historical interest) showed that there was something seriously wrong with vitamin B1 metabolism. He was treated exclusively with intravenous and oral nutrients that included thiamine disulfide (Post: March 16,2011, “A remarkable nutritional supplement”) and a complete removal of sugar in all its forms. His gradual improvement, for the first time since symptoms had begun, has been highly significant and has led to the introduction of another patient of a similar age. Although this second boy showed evidence of a vitamin deficiency other than thiamine, he has also shown great improvement with vitamin therapy. Since all vitamins contribute to oxidative metabolism, their absence represents a biochemical riddle that must be solved for each case. My conception of this disastrous disease is that the infiltration of the esophagus by these cells is a bizarre form of inflammation initiated by the brain . The changes in brain would occur because thiamine plays a vital role in oxidative metabolism, particularly in the lower brain that I have described as a computer (Posts: June 14, 2010; Oct 14, 2010; July 28, 2011.) Coughing in sleep is an example of an exaggerated reflex,similar to panic attacks  that are really just fragmented fight-or-flight reflexes fired because of brain sensitivity and without an observed physical danger. So this must give us thought about whether our present concept of separate, named and well defined diseases is an accurate representation of health decline. It would seem that the brain always plays a part in physical disease of the body and that no organic disease occurs without brain involvement. 1.Rosas-Ballina M, Tracey K J. The neurology of the nervous system: neural reflexes regulate immunity. Neuron 2009;64(1):28-32. 2.Blechert J, Wilhelm F H, Meuret A E, et al. Respiratory, autonomic, and experiential responses to repeated inhalations of 20% CO(2) enriched air in panic disorder, social phobia, and healthy controls. Biol Psychol 2010;84(1):104-111.