An Eye on Necrosis

Abstract

We present a case of acute esophageal necrosis (black esophagus) caused by iron pill esophagitis in a patient thirteen days status post combined heart and bilateral lung transplant who was supplemented with oral iron for anemia due to intraoperative blood loss. This case illustrates an unusual cause of acute esophageal necrosis and should be on the differential for patients with unexplained findings of esophageal necrosis who are also on iron supplementation. Case A 52 year old man with chronic right ventricular failure due to class I pulmonary hypertension and unrepaired total anomalous pulmonary venous return with Eisenmenger physiology underwent combined heart and bilateral lung transplantation. He received standard infectious prophylaxis, and started oral ferrous sulfate for anemia after passing a swallow evaluation. On postoperative day (POD) 11, he developed dysphagia and odynophagia. Esophagogastroduodenoscopy (EGD) performed on POD 13 showed circumferential necrosis of the esophagus with tongues of esophagitis proximally (Figure 1), and a stricture with luminal diameter of 6mm. Biopsies revealed necrotic tissue and brown pigment/crystalline material consistent with iron pill-induced esophageal necrosis (supported by positive iron stain) (Figure 2). Ischemia and infection were ruled out. Four months after discharge, EGD showed a 3 cm long fibrotic stricture 25 cm from the incisors 6 mm in diameter. There was mild erythema adjacent to the stricture with otherwise normal esophageal mucosa. Biopsies demonstrated normal squamous mucosa. He will undergo temporary esophageal stenting to treat the stricture. Discussion Ferrous sulfate was first reported to cause ulcerations of the hypopharynx and cervical esophagus in 1976. Severe gastrointestinal necrosis has been seen with iron overdose, however, not with therapeutic doses. In one series of 33 patients with iron pill induced upper gastrointestinal injury, 83% of biopsies contained ulcerative or erosive mucosal injury, but none contained necrosis. Acute esophageal necrosis remains a rare entity with well characterized clinical manifestations but poorly understood pathophysiology. It is suspected to result from ischemia and decreased mucosal defenses. Currently there are no reported cases of iron pill induced acute esophageal necrosis in the literature. This was a surprising finding and should be considered in patient with severe esophagitis or acute esophageal necrosis taking oral iron supplements.1770_A Figure 1 No Caption available.1770_B Figure 2 No Caption available.