Abstract
Aims
To explore the utility of an IgG4 immunohistochemical stain to help distinguish eosinophilic oesophagitis from gastroesophageal reflux disease.
Methods and results
We examined 21 cases of eosinophilic oesophagitis and 25 cases of gastroesophageal reflux disease. The diagnosis of eosinophilic oesophagitis was based on the presence of oesophageal dysfunction, >15 eosinophils per high-power field, and a lack of response to proton pump inhibitors. Gastroesophageal reflux disease showed intraepithelial eosinophils, but a clinical and/or histological response to proton pump inhibitor therapy. We also evaluated an additional cohort of 22 cases with intraepithelial eosinophils. Immunohistochemical staining for IgG4 was performed. Sixteen of 21 (76%) eosinophilic oesophagitis cases showed intrasquamous extracellular IgG4 deposits, whereas all 25 gastroesophageal reflux disease cases were negative. Mucosal IgG4-positive plasma cells were identified in eosinophilic oesophagitis and gastroesophageal reflux disease cases in 58% and 40% of cases, respectively. Eosinophilic oesophagitis patients receiving treatment were less likely to be positive for intraepithelial IgG4 deposits (88% versus 53%). In the validation cohort, the sensitivity and specificity for eosinophilic oesophagitis were 88% and 100%, respectively.
Conclusions
The presence of intrasquamous IgG4 deposits is a useful adjunctive marker in the distinction between eosinophilic oesophagitis and gastroesophageal reflux disease.
Keywords: eosinophilic oesophagitis, IgG4, IgG4-related disease, reflux oesophagitis, ultrastructural evaluation
Introduction
Eosinophilic oesophagitis is a clinicopathological condition characterized by dysphagia and food impaction, and the presence of intraepithelial eosinophils, typically >15 per high-power field (HPF).1–3 However, eosinophilia is a relatively non-specific finding, and the diagnosis of eosinophilic oesophagitis often requires the presence of a constellation of characteristic clinical and endoscopic findings, as well as a lack of response to proton pump inhibitors (PPIs).2,4
Although oesophageal eosinophilia is seen in a variety of diseases, the principal mimic of eosinophilic oesophagitis is reflux.2,4–6 Histologically, reflux oesophagitis is characterized by mild to moderate eosinophilia, generally localized to the distal oesophagus. Eosinophilic oesophagitis is characterized by superficial eosinophilic abscesses, submucosal fibrosis, and diffuse involvement of the oesophagus.5,6 However, eosinophilic abscesses are identified in only a fraction of cases, and lamina propria-based fibrosis is often difficult to distinguish from normal collagen present at this location. Furthermore, oesophageal involvement is frequently patchy, and hence biopsies may reveal relatively few eosinophils, a feature suggestive of reflux oesophagitis. Although the accepted threshold for a diagnosis of eosinophilic oesophagitis is 15 intraepithelial eosinophils per HPF, a lower number of cells does not exclude the diagnosis.2 Given the knowledge that the treatments for these two diseases differ widely, and the fact that histological features overlap frequently, a robust biomarker is urgently needed.
Eosinophilic oesophagitis is believed to represent an allergic response to environmental agents, mediated by T cells. Biopsies from patients with eosinophilic oesophagitis show elevated levels of interleukin (IL)-4, IL-5, and IL-13, which are important cytokines of the Th2 pathway, indicating Th2 polarization.7–9 IL-4 and IL-13, which are classic mediators of fibrosis, may account for the presence of fibrosis.10 IgG4-related disease is the other classic Th2-mediated disease characterized by elevated levels of IL-4, IL-5, and IL-13.10,11 IgG4-related disease characteristically shows elevated levels of serum and tissue IgG4, as well as fibrosis. Notably, markedly elevated numbers of IgG4-positive cells are present in biopsies from individuals with eosinophilic oesophagitis.12
The goal of the study was to evaluate a series of cases with elevated numbers of oesophageal eosinophils in order to evaluate IgG4 as a potential marker of eosinophilic oesophagitis and examine its ability to discriminate eosinophilic oesophagitis and reflux oesophagitis. Additionally, we validated the assay on a series of cases in which the initial diagnostic evaluation failed to distinguish between the two diseases.
Materials and methods
We identified 21 cases of eosinophilic oesophagitis and 25 cases of reflux oesophagitis (consecutive cases) from the files of Massachusetts General Hospital pathology department. This cohort was composed of cases with clinical and endoscopic findings characteristic of either eosinophilic oesophagitis or reflux oesophagitis. Patients with eosinophilic oesophagitis reported oesophageal dysfunction, had oesophageal biopsies showing >15 intraepithelial eosinophils per HPF, and responded to either topical steroids or food withdrawal therapy. Biopsies from both treatment-naïve individuals and individuals receiving therapy were examined. The diagnosis of reflux oesophagitis was based on a combination of features that included symptoms of heartburn and endoscopic findings that were either unremarkable or showed evidence of inflammation involving the distal portion of the oesophagus or the gastroesophageal junction. Additionally, patients showed a clinical and/or a histological response to PPI therapy. The presence of concomitant diseases, including Barrett’s oesophagus or congenital defects of the laryngotracheal region, were considered to be supportive evidence for reflux oesophagitis. Cases with significant eosinophilia in other regions of the gastrointestinal tract were excluded.
The results were validated on an independent cohort of cases with oesophageal eosinophilia. These patients differed from the original cohort in that eosinophilic oesophagitis could not be distinguished from reflux oesophagitis during the initial diagnostic evaluation. Typically, these cases showed features equivocal for eosinophilic oesophagitis. Atypical features included the lack of characteristic symptoms or endoscopic features of oeosinophilic esophagitis, a lower number of eosinophils, the absence of characteristic histological features of eosinophilic oesophagitis, and an equivocal response to PPI therapy. The final diagnosis was established on longitudinal follow-up, and was based primarily on the eventual response to either high-dose PPI therapy or topical steroid/food withdrawal.
Haematoxylin and eosin (H&E)-stained slides were evaluated for the presence and distribution of eosinophils. The peak oesophageal number was recorded, and expressed per HPF (size of the high-power field, 0.196 mm2). In addition, we recorded the presence of eosinophilic microabscesses (defined as an aggregate of five or more eosinophils) and submucosal fibrosis.
IMMUNOHISTOCHEMISTRY
Immunohistochemical staining for IgG4 was performed on all cases. In addition, 10 histologically unremarkable oesophageal biopsies were examined to evaluate the presence and extent of background staining. All staining was performed on the Leica Bond automated platform (Cell Marque; Rocklin, CA, USA clone MRQ-44; dilution 1:25). A control sample, i.e. a lymph node with elevated numbers of IgG4-positive plasma cells, was included on each slide as an internal control. The biopsies were examined for immunoglobulin precipitate and the presence of IgG4-positive plasma cells.
Both the immunohistochemical slides and the H&E-stained slides were reviewed in a blinded manner.
ULTRASTRUCTURAL EVALUATION
Ultrastructural evaluation was performed on one case each of eosinophilic oesophagitis and reflux oesophagitis. Briefly, representative areas were removed from the paraffin block. Paraffin was extracted by overnight soaking in xylene and successive treatment with decreasing (100%, 95%, 70%, 50%, and 25%) ethanol concentrations, followed by a buffer wash and a glutaraldehyde (2.5% glutaraldehyde, 2.0% paraformaldehyde and 0.025% CaCl in a 1.0 m sodium cacodylate buffer, pH 7.4) fixation step. Briefly, after fixation, tissues were dehydrated in a graded ethanol series, infiltrated with propylene oxide epoxy mixtures, and embedded in pure epoxy resin. Thin sections were cut, stained, examined with a Philips 301 (Philips, Einhoven, The Netherlands), and imaged with an Advanced Microscopy Techniques (Danvers, MA, USA) digital CCD camera.
The study was approved by Partners IRB. (IRB number 2014P002745; approval date 21 January 2015). Partners IRB has determined that informed consent was not required for this study.
Results
EOSINOPHILIC OESOPHAGITIS
The cohort was composed of 21 patients, including 16 males and five females (Table 1). The mean age of this cohort was 30 years. The majority of patients (n = 16) complained of dysphagia, several with symptoms (n = 4) over their entire lifetime. Other symptoms included food impaction requiring an endoscopic procedure to relieve symptoms (n = 7), cough, and vomiting. The endoscopic findings included linear furrows, white spots or plaques, and oesophageal rings.
Table 1.
Clinical characteristics of the study groups
| EoE, n = 21 | GERD, n = 25 | |
|---|---|---|
| Mean Age (range), (P = 0.24) | 30 (2–81) | 23 (1–81) |
| Male (P = 0.57), no. | 16 | 18 |
| Symptoms, no. | ||
| Dysphagia | 16 | 3 |
| Food impaction | 7 | 0 |
| Vomiting | 1 | 0 |
| Abdominal pain | 0 | 6 |
| Heartburn | 0 | 15 |
| Difficulty in eating | 1 | 0 |
| Cough | 2 | 1 |
| Others | 0 | 5* |
| Allergy | ||
| Asthma, eczema, allergic rhinitis | 14 | 1 |
| Endoscopic findings, no. | ||
| Furrows | 14 | 1 |
| White patches | 8 | 2 |
| Rings | 5 | 0 |
| Feline | 4 | 0 |
| Benign-appearing stricture | 2 | 0 |
| Others | 1† | 0 |
| Normal | – | 9 |
| Irregular Z line, erythema at GE junction | 0 | 14 |
EoE, eosinophilic oesophagitis; GE, gastroesophageal; GERD, gastroesophageal reflux disease.
Dental caries (1), asymptomatic (3), tracheomalacia (1).
Erythema.
REFLUX OESOPHAGITIS
The cohort was composed of 25 patients, including 18 males and seven females. The mean age of this cohort was 23 years. The patients complained of heartburn and regurgitation; other symptoms included cough and dental caries.
ALLERGY HISTORY
A history of allergy was identified in 14 (61%) patients with eosinophilic oesophagitis, and in one (5%) patient with reflux oesophagitis. Allergic rhinitis, asthma and eczema were the three most common allergic manifestations identified in this cohort.
LABORATORY INVESTIGATION FOR ALLERGY
The mean IgE level in patients with eosinophilic oesophagitis was 795 mg/dl (Table 2). Food-specific radioallergosorbent testing (RAST) gave positive results in 60% of patients with eosinophilic oesophagitis.
Table 2.
Histological characteristic of eosinophilic oesophagitis (EoE) and reflux oesophagitis
| EoE, n = 21 | GERD, n = 25 | |
|---|---|---|
| Mean intraepithelial eosinophils per HPF (P = 0.012) | 53 | 27 |
| Distribution of eosinophils, no. (%) | ||
| P = D | 6 (29) | 2 (11) |
| P > D | 11 (52) | 4 (21) |
| D > P | 4 (19) | 13 (68) |
| Fibrosis and eosinophilic abscesses, no. | ||
| Fibrosis and eosinophilic abscesses | 7 | 0 |
| Eosinophilic abscesses only | 2 | 0 |
| Fibrosis only | 5 | 3 |
| Absent eosinophilic abscess and fibrosis | 7 | 19 |
| IgE mg/dl, mean (range) | 795 (13–2240)* | 220 (14–512)† |
| RAST-positive, no. | 9/15 | 1/3 |
D, distal; GERD, gastroesophageal reflux disease; HPF, high-power field; P, proximal; RAST, radioallergosorbent testing.
Fibrosis analysed only in 21 cases.
Eleven cases.
Three cases.
EOSINOPHIL NUMBERS IN THE SQUAMOUS EPITHELIUM
Patients with eosinophilic oesophagitis (mean peak eosinophil count of 53 per HPF) showed significantly higher numbers of intraepithelial eosinophils than patients with reflux oesophagitis (mean peak eosinophil count of 27 per HPF) (P = 0.012) (Table 2). Patients with eosinophilic oesophagitis generally showed diffuse oesophageal involvement (as measured by the number of eosinophils), whereas reflux oesophagitis was typically limited to the distal portion of the oesophagus. Fifty-seven per cent of eosinophilic oesophagitis patients showed submucosal fibrosis, whereas nine (39%) patients showed abscesses composed of eosinophils (Figure 1A, B).
Figure 1.
A, Eosinophilic oesophagitis with marked basal cell hyperplasia and relatively few intraepithelial eosinophils. B, Fibrosis within the lamina propria. C, D, IgG4 immunoperoxidase stain performed on the biopsy depicted in (A). Note the strong granular reactivity between keratinocytes, and superficial layering. E, An immunohistochemical stain for IgG4 shows weak reactivity between keratinocytes. The image depicts the lower level of reactivity seen in this study. F, Subepithelial IgG4 deposits (arrows). C, D, E, F, IgG4 immunohistochemical stain.
IMMUNOHISTOCHEMISTRY FOR IGG4
To assess non-specific background staining, immunohistochemical staining was performed on 10 histologically unremarkable oesophageal biopsies: no reactivity was identified.
Sixteen of 21 (76%) patients with eosinophilic oesophagitis showed extracellular IgG4 deposits within the squamous epithelium (Figure 1C–E). Immunoreactivity was noted between the squamous cells, and was typically granular (Table 3). The immunoglobulin deposits were invariably identified between basal keratinocytes. In addition to basal reactivity, in eight patients (35%) the immune precipitate was also noted in the superficial portion of the squamous epithelium. All biopsies from patients with reflux oesophagitis were negative for IgG4 deposits.
Table 3.
Immunohistochemistry for IgG4 in cases of eosinophilic oesophagitis (EoE) and reflux oesophagitis
| IgG4 staining (P = 0.001), no. (%) |
Strong staining intensity, no. (%) |
Superficial pattern, no. (%) |
IgG4-positive stromal deposits in lamina propria* (P = 0.53), no. (%) |
IgG4-positive plasma cells present*† (P = 0.72), no. (%) |
>5 IgG4-positive plasma cells*, no. (%) |
|
|---|---|---|---|---|---|---|
| EoE (n = 21) | 16/21 (76) | 14/16 (88) | 8/21 (38) | 10/19 (53) | 11/19 (58) (mean 12.5 per HPF) | 6/19 (32) |
| GERD (n = 25) | 0/25 (0) | 0/25 (0) | 0/25 | 6/15 (40) | 6/15 (40) (mean 8.8 per HPF) | 5/15 (33) |
GERD, gastroesophageal reflux disease; HPF, high-power field.
Adequate lamina propria to assess IgG4 was available in only 19 and 15 cases of EoE and reflux oesophagitis, respectively.
Only positive cells beneath squamous epithelium were scored.
In addition to the intraepithelial deposits of IgG4, submucosal IgG4-positive plasma cells were also identified in 58% of patients (Figure 2): IgG4-positive plasma cells were also identified in 40% of patients with reflux oesophagitis [P not significant (NS)]. Similarly, extracellular IgG4 deposits within the lamina propria were noted in approximately one-third of patients in both groups (Figure 1f) (P NS).
Figure 2.
Eosinophilic oesophagitis with large numbers of IgG4-positive plasma cells in the lamina propria.
COMPARISON OF TREATMENT - NAïIVE PATIENTS WITH PATIENTS RECEIVING TOPICAL STEROIDS / FOOD WITHDRAWAL THERAPY
A higher proportion of treatment-naïve eosinophilic oesophagitis patients showed intrasquamous IgG4 deposits, although this difference was not statistically different (P = 0.1) (Table 4). Similarly, there was a decrease in the number of patients with reactivity of the superficial squamous epithelium (P = 0.07). There were no significant differences in the mean numbers of IgG4-positive plasma cells (P = 0.4) or IgG4 deposits within the lamina propria between the two cohorts (P = 0.5).
Table 4.
Relationship between IgG4 and therapy
| Intraepithelial eosinophils per HPF |
IgG4 epithelium (P = 0.1), no. (%) |
Superficial pattern (P = 0.07), no. (%) |
Strong staining intensity, no. (%) |
IgG4-positive plasma cells present*,† (P = 0.4), no. (%) |
IgG4-positive stromal deposits (P = 0.5), no. (%) |
|
|---|---|---|---|---|---|---|
| EoE initial presentation, n = 8 | 43 | 7/8 (88) | 6/8 (75) | 8/8 (100) | 6/7 (86) (mean 22.4) | 6/7 (86) |
| EoE on therapy, n = 13 | 44 | 7/13 (53) | 3/13 (23) | 6/13 (46) | 6/12 (50) (mean 7.0) | 6/12 (50) |
EoE, eosinophilic oesophagitis; HPF, high-power field.
Only positive cells beneath squamous epithelium were scored.
Adequate lamina propria to assess IgG4 was available in only 19 cases.
ULTRASTRUCTURAL EVALUATION
Ultrastructural evaluation supported the immunohistochemistry findings: electron-dense immune deposits between keratinocytes and within the lamina propria (Figure 3). These deposits were not identified in patients with reflux oesophagitis.
Figure 3.
Electron-dense deposits (arrows) between squamous cells (A) and the lamina propria (B).
VALIDATION COHORT
These results were validated in an independent cohort that included both patients with eosinophilic oesophagitis (n = 14) and patients with reflux oesophagitis (n = 8). The clinical and endoscopic features of the patients with eosinophilic oesophagitis were predictably less characteristic of the disease (Tables 5 and 6; Table S1). The majority of patients (n = 17) showed >15 eosinophils per HPF, whereas four patients showed 5–15 eosinophils per HPF. Nevertheless, the overwhelming majority of patients showed intrasquamous IgG4 deposits, whereas patients with reflux oesophagitis were negative for intrasquamous deposits. Subepithelial IgG4-positive cells could not distinguish the two diseases (data not shown).
Table 5.
Clinical features of the validation cohort
| EoE, n = 14 | GERD, n = 8 | |
|---|---|---|
| Mean Age (range) | 22 (5–44) | 26 (7–61) |
| Male, no. | 7 | 18 |
| Symptoms, no. | ||
| Dysphagia | 5 | 1 |
| Food impaction | 4 | 0 |
| Vomiting | 2 | 1 |
| Abdominal pain | 1 | 3 |
| Heartburn | 3 | 4 |
| Cough | 1 | |
| Endoscopic findings, no. | ||
| Furrows | 4 | 4 |
| White patches | 1 | 2 |
| Rings | 0 | 0 |
| Feline | 0 | 0 |
| Benign-appearing stricture | 1 | |
| Diffuse erythema and nodularity | 1 | 0 |
| Normal | 2 | 3 |
| Distal oesophageal erythema | 2 | 2 |
EoE, eosinophilic oesophagitis; GERD, gastroesophageal reflux disease.
Table 6.
Validation cohort: immunohistochemistry for IgG4
| IgG4 staining, no. (%) |
Strong staining intensity, no. (%) |
Superficial pattern, no. (%) |
|
|---|---|---|---|
| EoE (n = 14) | 12/14 (93) | 10 (71) | 5 (36) |
| GERD (n = 8) | 0/8 (0) | 0/8 (0) | 0/8 (0) |
EoE, eosinophilic oesophagitis; GERD, gastroesophageal reflux disease.
Discussion
The aetiological distinction between the most common causes of intraepithelial eosinophils, reflux oesophagitis and eosinophilic oesophagitis is difficult, and remains uncertain in many cases. The study suggests that the presence of intrasquamous IgG4 deposits, typically granular intercellular deposits, can help to distinguish eosinophilic oesophagitis from reflux oesophagitis with high sensitivity and specificity. The data were validated on an independent cohort of diagnostically challenging cases. The sensitivity was higher for treatment-naïve patients (89%) than for patients receiving therapy (50%). Although IgG4-positive plasma cells and IgG4 deposits in the lamina propria were identified more consistently in patients with eosinophilic oesophagitis, the significant overlap between the two cohorts precludes their use as discriminatory biomarker.
Our data validate a recent study that evaluated IgG4-positive cells in patients with eosinophilic oesophagitis.12 These authors identified extracellular IgG4 deposits in 21 of 24 patients with eosinophilic oesophagitis, but in none of the nine controls, although the composition of the latter group was not specified.12
A potential pitfall, as is the case with all immunoglobulin stains, is that of non-specific background signals. Somewhat counterintuitively, non-specific staining was seldom observed on oesophageal samples, and, when present, was typically pale and lacked the granular quality seen in eosinophilic oesophagitis. The location of the deposits also helped to exclude a background signal—reactivity in eosinophilic oesophagitis is typically located between basal keratinocytes, although the more intensely reactive cases showed staining in the superficial layers of the epithelium as well.
Fibrosis is a characteristic feature of both IgG4-related disease and eosinophilic oesophagitis, although the quality and the pattern of fibrosis are generally dissimilar: IgG4-related disease is typified by storiform-type fibrosis, whereas eosinophilic oesophagitis shows a ‘pattern-less’ pattern of fibrosis.5,13 The presence of IgG4 and fibrosis raises the intriguing hypothesis that the two diseases are more closely aligned than the current evidence suggests. Although the two diseases show little clinical overlap, it is conceivable that the biological basis may be similar.
Whereas the Th2-dominant cytokine milieu provides a rational explanation for the presence of IgG4 (these cytokines are key to isotype switching), the role of IgG4 in eosinophilic oesophagitis remains to be clarified. Unlike most antibodies, IgG4 is believed to be a suppressor rather than a cytotoxic antibody.14 IgG4 is functionally monovalent; each antibody may show (the extent of in-vivo Fab arm exchange is uncertain) two distinct antigen recognition sites, a consequence of inefficient disulphide bridges between the heavy chains of the molecule, resulting in Fab arm exchange. Furthermore, failure to bind FcRs and C1q efficiently makes it ineffective at phagocyte activation, antibody-dependent cellular cytotoxicity, and complement-mediated damage.14 The excess IgG4 in eosinophilic oesophagitis could represent an attempt to quench the allergic reaction, a line of reasoning supported by the decrease in epithelial IgG4 deposits in patients receiving therapy. Although IgG4-positive plasma cells are also identified in reflux oesophagitis, the immunoglobulin deposits do not extend into the squamous epithelium in these cases. Notably, IgG4 deposits are also detected in IgG4-related disease.15,16
The IgG4 response within the squamous epithelium appears to diminish with therapy, raising the possibility that IgG4 is a marker of disease activity. However, this study lacks the power needed to address this question. Interestingly, there was no difference in the number of IgG4-positive plasma cells between treatment-naïve patients and patients receiving therapy. The IgG4-positive plasma cells thus represent persistent plasma cells (as opposed to short-lived plasma cells), and neither food withdrawal nor topical antibiotics deplete the local source of the antibody. Nevertheless, it is likely that intrasquamous IgG4 deposits play a protective rather than a cytotoxic role.
A tissue IgG4 stain represents one of a growing number of potential biomarkers for eosinophilic oesophagitis. Arachidonate-15 lipoxygenase (ALOX15), which was identified in squamous cells in 95% of patients with eosinophilic oesophagitis, was also present in patients with reflux, albeit in a lower percentage of cases.17,18 Using a 96-gene quantitative polymerase chain reaction array, Wen et al. could discriminate eosinophilic oesophagitis from reflux oesophagitis with a sensitivity of 96% and a specificity of 98%.19 The assay, although adapted to paraffin- embedded material, lacks the convenience of immunohistochemistry. Several genes characteristic of the Th2 pathway were included in this array, including those encoding IL-4, IL-5, and IL-13, but IgG4 was not. Another promising biomarker, eotaxin-3, an eosinophil-specific chemoattractant, is encoded by a highly induced gene in patients with eosinophilic oesophagitis.20 Dellon et al. examined the diagnostic utility of major basic protein and eotaxin-3 in distinguishing eosinophilic oesophagitis from reflux oesophagitis.21 Although patients with eosinophilic oesophagitis had substantially higher levels of major basic protein and eotaxin-3, patients with reflux oesophagitis were also reactive for these markers, although, in this latter group, a smaller percentage of squamous cells stained for these markers.
A potential failing of this study lies in its retrospective nature. We took great care to identify cases that met the modern definition of eosinophilic oesophagitis: (i) symptoms related to oesophageal dysfunction; (ii) a peak eosinophil count of >15 per HPF; (iii) mucosal eosinophilia limited to the oesophagus; and (iv) symptoms and pathology that did not respond to PPI therapy. Nevertheless, it would be remiss to ignore the complex relationship between gastroesophageal reflux disease and eosinophilic oesophagitis: eosinophilic oesophagitis may precipitate reflux, a consequence of impaired oesophageal sphincter function, and, in turn, reflux could induce an allergic response as a result of a leaky epithelial barrier.
Additionally, this study did not evaluate PPI-responsive eosinophilic oesophagitis (PPI-REE), a disease that shows significant clinical and endoscopic overlap with eosinophilic oesophagitis, primarily because of the lack of widely accepted diagnostic criteria and the inability to confidently identify cases in a retrospective cohort. This condition is typically suspected in patients with oesophageal dysfunction and eosinophilia, and symptoms respond to PPIs. Interestingly, a recent study showed that untreated PPI-REE has a molecular signature remarkably similar to that of eosinophilic oesophagitis, arguing that the two diseases form part of the same spectrum.22
In conclusion, the presence of intrasquamous IgG4 immunoglobulin precipitate could aid in distinguishing eosinophilic oesophagitis from reflux oesophagitis. Unlike other novel markers, the IgG4 immunostain is available in most pathology laboratories, as a side-effect of the widespread appreciation of IgG4-related disease. Also, unlike some biomarkers, intrasquamous IgG4 deposits appear to be independent of eosinophils, an assertion supported by the decrease in intrasquamous IgG4 deposits independently of tissue eosinophilia.
Supplementary Material
Footnotes
Author contributions
L. Zukerberg and V. Deshpande conceived the study, and contributed to the design of the study, data collection, and writing of the manuscript. K. Mahadevan performed immunohistochemistry and assisted in data collection. M. Selig assisted with the ultrastructural portion of the study.
- Table S1. Difficult cases.
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