The FIRE phenomenon and Eosinophilic Esophagitis (EoE)
During my son’s most recent food challenge, he was beginning to feel discomfort in his throat and upper chest after his first bite of baked egg. His allergist paused as we discussed with my son exactly what he was feeling. Then he was checked for hives and his breathing was thoroughly monitored. A decision was then made — after discussing with my son and confirming that he was in agreement — that we would continue to the next scheduled dose.
After that second dose my son said the discomfort was becoming more pronounced. His breathing was still unaffected, no hives or nasal congestion, but he was having more tightness in his chest. He was instructed to drink water as needed and that we would wait a few more minutes.
He eventually made it to a full half of a muffin with baked egg – until he had to stop due to the discomfort. I was confused. The reaction didn’t appear to be progressing to full IgE-mediated signs and symptoms of anaphylaxis, but his discomfort had progressed and he was visibly concerned.
So I asked the allergist, “What exactly is happening?”
His allergist said, “…it seems like FIRE.”
I said, “What does that mean?”
The allergist said, “Oh, it’s relatively a new discovery, but it is very common with patients with eosinophilic esophagitis (EoE)…”
I sat there dumbfounded and confused.
So as I waited more to see how his symptoms might progress I googled the terms ‘FIRE’ and ‘eosinophilic esophagitis’ – and there it was:
FIRE (food-induced immediate response)
FIRE (food-induced immediate response) is a more recent phenomenon described in eosinophilic esophagitis (EoE) patients. Food-induced immediate response of the esophagus is an unpleasant/painful sensation, unrelated to dysphagia, occurring immediately after esophageal contact with specific foods… Symptoms included narrowing, burning, choking, and pressure in the esophagus appearing within 5 minutes of ingesting a provoking food... – Luc Bierdermann et al. Allergy. 2021 Jan; Gizem Koken et al. Allergy. 2023 Dec
I’m still processing all of the questions that have come to mind that I need to discuss with his allergist and gastroenterologist, including:
· What about Dupixent that my son is on to control his EoE, shouldn’t that prevent these kinds of reactions? (I did get a bit of an answer to this; that answer blew my mind even more…stay tuned)
· How do I now teach my teenage son to recognize anaphylaxis vs. an EoE FIRE reaction, and not wait to epi when it’s needed?
· We just identified another EoE trigger food to add to the confirmed list, can this firmly confirm inflammation so he can skip a follow up endoscopy?
· Etc, etc, etc…
I’ll continue to share more as I get answers. In the meantime, if you’re interested in reading more about FIRE and EoE – check out the articles below for reference.
And, an update on my son — he’s doing fine and we’re moving forward after the disappointment from this oral food challenge that didn’t end how we had hoped. We certainly have learned something that may be a key to understand future reactions and how to be safe as the college years quickly approach.
Any questions, feel free to reach out here.
Articles of interest:
https://pubmed.ncbi.nlm.nih.gov/37701950/
https://pubmed.ncbi.nlm.nih.gov/32662110/