1740 Syphilitic Lichenoid Esophagitis: A Rare Finding

Abstract

INTRODUCTION: Extra-genital manifestations involving gastro-intestinal tract is extremely rare. We describe a case of biopsy-proven esophageal syphilis causing extremely rare pathological diagnosis of lichenoid esophagitis. CASE DESCRIPTION/METHODS: A 50 year-old woman with HIV-AIDS, HCV cirrhosis and recent anterior syphilitic uveitis presented with 4 days of melena. Esophagoduodenoscopy showed severe inflammation with LA grade D esophagitis. Mid esophagus had severe ulceration with crater formation and a stricture was noted at 35 cm (Figure 1). Histopathology of the biopsies showed marked intraepithelial lymphocytes, neutrophils, dyskeratotic keratinocytes (Civatte bodies) and dense band-like lymphoplasmocytic infiltrates in the lamina propria, consistent with lichenoid injury pattern (Figure 2), and visualization of spirochetes in the mucosa (Figure 3). No fungal elements or viral inclusion bodies were noted. Immunochemical staining was negative for CMV and HSV I/II. She was treated with a 14-day course of Penicillin G and reported complete resolution of symptoms on follow-up visit. DISCUSSION: Treponema pallidum rapidly spreads via the blood stream and lymphatics after the initial inoculation and can disseminate multiple foci to visceral organs including the gastrointestinal tract. Most common sites reported are oral cavity, stomach, rectum and rarely esophagus (1). T. pallidum incites an immune response with proliferative endarteritis affecting small vessels surrounded by T-lymphocytes, plasma cells and macrophages. This leads to extensive mucosal injury seen as diffuse esophagitis along with focal ulceration, which is prone to bleeding (2). The lichenoid pattern of injury with band-like infiltrate of lymphocytes in lamina propria and scattered degenerated keratinocytes (Civatte bodies) is atypical of syphilitic injury. This may cause fibrosis of the esophageal mucosa leading to stenosis and stricture (3). Salaria et. al. found that patients with lichenoid esophagitis were more likely to have concurrent HIV or viral hepatitis and were taking >3 medications (4).