An Unsual Case of Severe Pill Esophagitis Mimicking Herpetic Esophagitis, Caused by a New OTC NSAID – Containing Sleeping Aid

Abstract

We present a case of severe NSAID induced esophagitis, mimicking severe herpetic esophagitis, caused by a new sleeping aid OTC preparation that combines naproxen and diphenhydramine. This type of preparation caused severe injury to the esophagus, its use as a bedtime sleeping aid, greatly increasing the risk of pill induced esophagitis. We could find no product labeling warning patients of this potential complication. This 37 yo man with a hx of dyspepsia, IBS, and chronic insomnia, developed acute severe odynophagia, which did not respond to PPI's, or antacids, only able to swallow small amounts of liquids. He repeatedly denied taking any pills associated with pill induced esophagitis. Urgent EGD revealed very severe discontinuous ulcerations with almost complete slough of the distal esophageal mucosa, suggestive of severe herpetic esophagitis. Biopsies and viral cultures were negative for herpes. Patient improved with the addition of liquid sucralfate qid. On subsequent questioning he remembered taking a naproxen containing sleeping aid (Advil-PM®) at bedtime with little water for several days prior to the symptoms. The preparation was stopped, syptoms resolved, and repeat endoscopy showed healing of the ulcerated esophageal mucosa. Many patients take sleeping aids for insomnia, that typically have acetominephen and diphenhydramine, such as Tylenol PM®. We were suprised to learn of the existence of a similar OTC NSAID preparation (Advil PM®). In our previous case-controlled study (Gastrointest Endoscopy 2004; 59:AB240) NSAID's were the most common cause of pill induced esophagitis. A preparation that combines an NSAID with a sleeping aid, carries particular risk for inducing pill-induced esophagitis, due to its bed-time use. Patients need to be cautioned about this potential side effect of this type of preparation. The injury was particularly severe, but responded to NSAID cessation, and PPI and sucralfate therapy. Clinicians need to be aware of new sleeping aid OTC preparations that contain NSAID's, caution patients about their potential for inducing pill esophagitis, and question patients with unexplained esophageal ulcerations and odynophagia about their use.