dolr cyriac abby phillips( liver doc) advised skin prick test( allergy test) for 28 yr old female with history of excessive cough while eating causing to nauseate and vomit for last 2 to 3 years. symptoms subside on inhaled budecort . restarts in 1 or 2 months after stoppage. gerd ruled out as no improvement on treatment. liver is normal, fibroscan normal. how to do test , whom to consult, where to go , patient is from trivandrum. what are your top dds.
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PMID: 38656287
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IRIS allergy hospital Trivandrum gastroenterologist eosinophilic esophagitis Kerala referral 2025
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Clinical Analysis: 28-Year-Old Female with Cough-While-Eating, Nausea/Vomiting, Responds to Budecort (Budesonide), GERD Ruled Out
This is a classic presentation that points very strongly in one direction. Here is the full breakdown.
Top Differential Diagnoses
#1 - Eosinophilic Esophagitis (EoE) - Highest Probability
Every feature of this case maps to EoE:
| Patient's Feature | EoE Explanation |
|---|---|
| Cough while eating | Esophageal dysfunction causes reflexive cough |
| Nausea and vomiting while eating | Food impaction, poor peristalsis, eosinophilic inflammation |
| Symptoms for 2-3 years | Chronic, slowly evolving disease - often misdiagnosed for years |
| Responds to inhaled budesonide | EoE responds to topical corticosteroids; budesonide is first-line treatment |
| Symptoms return 1-2 months after stopping | Classic relapse pattern - EoE requires maintenance therapy |
| GERD ruled out (no PPI response) | Supports EoE over GERD |
| Normal liver/fibroscan | Excludes hepatic causes |
| Young adult female | EoE is seen in this demographic, though slightly more common in males |
Note: The "inhaled" budesonide (Budecort) she is using was originally an asthma inhaler - when patients accidentally swallow the drug (or use it as a slurry), it acts as a topical esophageal steroid and relieves EoE. The 2025 ACG guidelines on EoE specifically emphasize the allergist-gastroenterologist co-management model that applies here.
#2 - Achalasia / Esophageal Dysmotility
- Poor peristalsis causing cough and regurgitation while eating
- Does not explain the steroid response
- Less likely but needs exclusion via manometry or barium swallow
#3 - Food-Triggered Allergic Reaction (IgE-mediated)
- Immediate symptoms to specific foods
- Could coexist with EoE (atopic background)
- Skin prick test is relevant here
#4 - Cough-Variant Asthma / Laryngopharyngeal Reflux (LPR)
- Budecort's anti-inflammatory effect helps both asthma and airway inflammation
- But the strict trigger during eating makes asthma alone less likely
- LPR usually responds to PPI to some extent; this case did not
#5 - Laryngeal Hypersensitivity / Vagal Reflex Cough
- Eating triggers a vagally mediated cough
- Some cases overlap with EoE
What is a Skin Prick Test (SPT) and Why Was It Advised?
Dr. Abby Phillips correctly recognized that EoE is an allergen-driven disease - up to 90% of EoE cases are triggered by specific food allergens. The skin prick test (SPT) identifies IgE-mediated hypersensitivity to specific allergens.
How the Test is Done
-
Preparation (2-3 days before):
- Stop antihistamines (cetirizine, loratadine, etc.) for at least 3-7 days before the test
- Stop tricyclic antidepressants if any
- Do NOT stop steroids or beta-blockers (inform doctor)
- Avoid applying any creams to the test area (inner forearm or back)
-
The procedure (takes ~30 minutes total):
- The forearm or upper back skin is cleaned
- A grid of small marks is drawn, each labeled for a specific allergen
- A drop of each allergen extract is placed on the skin
- A small lancet (prick device) is pressed through each drop to introduce the allergen into the superficial skin (not a deep injection - just a prick)
- A positive control (histamine) and negative control (saline) are included
- After 15-20 minutes, the skin is examined for a wheal (raised bump) and flare (redness)
- A wheal ≥3 mm larger than the negative control is considered positive
-
For EoE, the allergens tested include:
- Milk (casein), wheat/gluten, egg, soy, peanut, tree nuts, fish, shellfish
- Locally relevant Kerala food allergens (rice, coconut, spices) - the Trivandrum Drug Allergy Testing Centre specifically offers "skin prick test for commonly consumed Kerala food"
-
Important limitation: Standard skin prick testing for food has limited sensitivity for EoE specifically (unlike immediate food allergy). Elimination diet trials guided by allergy testing are often more useful than SPT alone for identifying EoE triggers.
Where to Go in Trivandrum
Option 1 - IRIS Allergy Hospital, Thiruvananthapuram (Best Option for This Case)
- Full allergy and immunology centre in Trivandrum
- Offers skin prick test, food allergy testing, blood tests, patch tests
- Multidisciplinary: Immunology + Pulmonary Medicine + Dermatology under one roof
- Contact: +91 82814 45394
- Email: info@irisallergy.com
- Address: Malayil Centre, Chenthi, Pongumoodu, Thiruvananthapuram, Kerala 695011
- Website: irisallergy.com
Option 2 - Trivandrum Drug Allergy Testing Centre (Dr. Venugopalan P G)
- Specifically offers skin prick test for food allergens including Kerala food allergens
- Contact: +91 944 705 4217 / +91 944 742 4940
- Address: Suha Residency, Poonthi Rd, Kumarapuram, Thiruvananthapuram - 695011 (opposite PRAN Fertility Centre ANNEXE, near KIMS)
- Website: drugallergytest.com
Option 3 - Gastroenterology at Government Medical College (GMC) Trivandrum or KIMS/PVS Hospital
- For upper GI endoscopy with biopsy (the gold-standard confirmation of EoE - must show ≥15 eosinophils per high-power field)
- Dr. Abby Phillips (liver hepatologist) has likely already considered this - the SPT is the next adjunct step
Whom to Consult and in What Order
The 2025 ACG/AAAAI guidance on EoE explicitly recommends joint gastroenterologist + allergist-immunologist management.
- Allergist/Immunologist - for skin prick test, food panel IgE testing, management of atopic comorbidities → IRIS Allergy Hospital or Trivandrum Drug Allergy Centre (above)
- Gastroenterologist - for upper GI endoscopy with multiple biopsies (proximal + distal esophagus) to confirm EoE histologically. This is non-negotiable for diagnosis.
- Pulmonologist (if not already done) - to exclude coexisting asthma or laryngeal pathology
Recommended Workup in Order
| Step | Investigation | Purpose |
|---|---|---|
| 1 | Skin prick test + serum specific IgE panel (food panel) | Identify allergic triggers |
| 2 | Upper GI endoscopy with biopsy (multiple sites) | Gold standard for EoE - ≥15 eos/HPF |
| 3 | Barium swallow / esophageal manometry | Exclude achalasia/dysmotility |
| 4 | Blood CBC with differential | Peripheral eosinophilia (found in ~50% EoE) |
| 5 | Total serum IgE | Elevated in atopic/allergic states |
| 6 | Elimination diet trial (6-food elimination: milk, wheat, egg, soy, nuts, seafood) | Therapeutic-diagnostic; if symptoms resolve, rechallenge each food group |
Treatment Implications (If EoE Confirmed)
- Swallowed topical budesonide (not inhaled - swallowed as a slurry) is first-line; the patient is already partially using budesonide, which explains the symptom relief
- Proper formulation: Budesonide 0.5-1 mg mixed with a small amount of viscous material (Splenda or glucose syrup) and swallowed - not inhaled - to coat the esophagus. The patient's inhaled Budecort may be partially swallowed, explaining the partial response.
- Dietary elimination based on SPT/IgE results
- Dupilumab (anti-IL-4/IL-13 biologic) - FDA/DCGI approved for EoE, highly effective for steroid-refractory cases
- Maintenance therapy is essential - this is a chronic relapsing condition; stopping treatment leads to recurrence (as seen in this patient)
Bottom line: This patient almost certainly has Eosinophilic Esophagitis (EoE). The skin prick test advised by Dr. Abby Phillips is appropriate. She should go to IRIS Allergy Hospital, Trivandrum (+91 82814 45394) for the SPT and food allergen panel, and simultaneously be referred to a gastroenterologist for upper GI endoscopy with esophageal biopsy to confirm the diagnosis. Once confirmed, she needs proper swallowed budesonide (not just inhaled), and possibly a supervised elimination diet.
Sources: K.J. Lee's Essential Otolaryngology (Food Allergy workup); Caminati et al., Curr Opin Allergy Clin Immunol 2024 [PMID 38656287]; ACG/AAAAI EoE guideline update 2025 [PMID 40339609]; IRIS Allergy Hospital Trivandrum; Trivandrum Drug Allergy Testing Centre.
can it be due to respiratory causes
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Yes - respiratory causes are genuinely plausible and should not be dismissed. Here is a structured analysis:
Can Respiratory Causes Explain This Patient's Symptoms?
Short answer: Yes, and some of them fit very well. The features that point toward a respiratory component are:
- Cough triggered specifically while eating
- Response to inhaled budesonide (a respiratory drug in its original form)
- No GERD response
- Young female
Let's go through each respiratory possibility honestly:
Respiratory Differentials - Ranked by Fit
1. Laryngeal Hypersensitivity Syndrome (Cough Hypersensitivity Syndrome)
Fit: HIGH
This is one of the most underdiagnosed causes of chronic cough in young women. According to Murray & Nadel's Textbook of Respiratory Medicine:
"Idiopathic cough may be caused by an increased sensitivity of the larynx to innocuous stimuli - symptoms of laryngeal paraesthesia with cough associated with dyspnea, dysphonia, and laryngeal spasms. Related diseases such as GERD, rhinosinusitis, and asthma may act as triggers to laryngeal hypersensitivity."
Key features in this patient that fit:
- Cough triggered by a specific mechanical stimulus (eating/swallowing)
- Leads to nausea and vomiting (violent, repeated coughing paroxysms can cause vomiting - this is a valsalva/cough-induced emesis, not true GI nausea)
- Responds to corticosteroids (reduces airway inflammation driving the sensitized laryngeal reflex)
- Chronic, relapsing course
- More common in women
Why vomiting with cough? Prolonged cough paroxysms increase intrathoracic and intraabdominal pressure, trigger the vomiting reflex via the vagus nerve - this is called cough-induced emesis and does NOT mean the problem is gastrointestinal.
2. Upper Airway Cough Syndrome (UACS) / Post-Nasal Drip
Fit: MODERATE
The triad of chronic cough causes in respiratory medicine (Harrison's, Goldman-Cecil, Murray & Nadel) is:
- Post-nasal drip / Upper Airway Cough Syndrome
- Asthma
- GERD
UACS causes a chronic tickle/drip sensation that triggers cough, sometimes during meals (eating increases salivation and swallowing, which can mobilize post-nasal secretions). Corticosteroids (inhaled or intranasal) help.
Against it: UACS does not typically cause vomiting and usually has nasal/sinus symptoms. Ask: does she have chronic nasal congestion, post-nasal drip sensation, or sinusitis?
3. Cough-Variant Asthma / Eosinophilic Bronchitis
Fit: MODERATE
- Responds to budesonide - fits perfectly
- Food smells, chewing, cold air during eating can all trigger bronchospasm in asthmatic airways
- Can cause vomiting with severe cough bouts
- No wheeze needed (cough-variant asthma is by definition "cough only")
Critical question: Does the cough happen only while eating, or also at other times? If it happens only during eating, asthma becomes less likely (asthma cough is more diffuse in trigger pattern). If food smells, cold food, or eating in general triggers it, food-triggered bronchospasm is possible.
Investigation: Spirometry with bronchodilator reversibility test, and ideally a methacholine challenge test (bronchoprovocation) - both available at IRIS Allergy Hospital or KIMS Trivandrum.
4. Dysphagia-Related Aspiration / Silent Aspiration
Fit: LOW-MODERATE
When swallowing coordination fails, food/liquid can "flash penetrate" into the larynx, triggering an immediate protective cough reflex. This is more common in:
- Neurological conditions (stroke, MS, myopathy)
- Post-surgical states
- Structural pharyngeal/esophageal problems
In a 28-year-old with no neurological history, this is less likely but cannot be excluded without a videofluoroscopic swallow study (VFSS) or functional endoscopic evaluation of swallowing (FEES) - both done by speech-language pathologists and ENT.
5. Tracheobronchomalacia (TBM)
Fit: LOW
TBM (weak/floppy airway walls that collapse during breathing) can cause cough triggered by increased intrathoracic pressure, such as during eating (valsalva). However:
- Usually presents with a barking cough, stridor, recurrent pneumonias
- Not specifically triggered by eating alone
- Less likely in a 28-year-old without childhood history of breathing problems
The Critical Distinction: What Kind of Vomiting?
This is the most important differentiating question:
| Type | What it means |
|---|---|
| Cough-induced vomiting - she coughs so violently that she vomits at the end of a cough bout | Points to respiratory cause (laryngeal hypersensitivity, cough-variant asthma) |
| Nausea then vomiting - she feels nauseated first, then vomits, cough is secondary | Points to esophageal/GI cause (EoE, dysmotility) |
| Food coming back up - regurgitation during eating | Points to EoE, achalasia, Zenker's diverticulum |
If the sequence is: eating → cough paroxysm → vomiting at end of cough - this is respiratory.
If the sequence is: eating → nausea/food feeling stuck → vomiting → cough - this is esophageal.
What Investigations Specifically Address Respiratory Causes
| Test | What it checks | Where in Trivandrum |
|---|---|---|
| Spirometry + bronchodilator reversibility | Cough-variant asthma, obstruction | Any pulmonology dept - KIMS, SAT Hospital, IRIS |
| Methacholine/AMP challenge | Airway hyperreactivity (asthma without wheeze) | KIMS Trivandrum, Medical College |
| Flexible nasoendoscopy / laryngoscopy | Laryngeal hypersensitivity, vocal cord dysfunction, post-nasal drip | ENT at any tertiary centre |
| FEES or VFSS (swallow study) | Silent aspiration, pharyngeal dysmotility | Speech therapy dept, Medical College Trivandrum |
| HRCT chest | Bronchiectasis, interstitial lung disease from chronic aspiration | Any radiology centre |
| FeNO (fractional exhaled nitric oxide) | Eosinophilic airway inflammation | KIMS, specialized pulmonology |
Revised Working Diagnosis Framework
Given that:
- She responds to budesonide (works for both airway and esophageal eosinophilic disease)
- GERD is ruled out (no PPI response)
- Liver is normal
- Symptoms are strictly eating-related
The two most likely diagnoses remain EoE and laryngeal hypersensitivity/cough-variant asthma - and importantly, these two can coexist. About 30-50% of EoE patients have coexisting airway atopy (asthma, allergic rhinitis). The skin prick test advised by Dr. Abby Phillips addresses the allergic component that underpins both.
The ideal next step is a combined workup:
- Pulmonology referral: spirometry + bronchoprovocation + FeNO (to address respiratory angle)
- ENT/laryngoscopy: to visualize larynx and rule out vocal cord dysfunction
- Upper GI endoscopy with biopsy: to confirm or exclude EoE
- Allergy testing (SPT + serum IgE): already planned
Dr. Shehanaaz Begum (MD, DNB Pulmonary Medicine + MRCP-SCE Respiratory Medicine) at IRIS Hospital, Trivandrum would be an excellent referral for the respiratory component alongside the allergy evaluation - she specializes in respiratory allergies.
Sources: Murray & Nadel's Textbook of Respiratory Medicine; Harrison's Principles of Internal Medicine 22E; K.J. Lee's Essential Otolaryngology; Cough hypersensitivity and chronic cough - PMC
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