An Unusual Cause of Dysphagia

Abstract

Purpose: Lymphocytic esophagitis (LE) is a newly recognized histological pattern of esophageal injury. It is characterized by an increased number of intraepithelial lymphocytes without associated intraepithelial granulocytosis in the peripapillary fields of esophageal tissue. It typically presents with dysphagia and sometimes chest pain. The esophageal endoscopic findings are commonly normal. We present a case of a patient with recurrent dysphagia that was found to have histological evidence of LE. The individual is a 47-year-old man with history of Hodgkin's lymphoma at 23 years of age who was treated with splenectomy followed by chemotherapy and mantle field radiation completed 24 years ago. He currently has no evidence of disease. He presented with recurrent and progressive dysphagia for 2 years. His symptoms were initially alleviated by a proton pump inhibitor but recurred 1.5 years later. He had dysphagia daily and it was mostly to solids but occurred occasionally with liquids. He described a sensation of food getting stuck high in the esophagus for several seconds that ultimately passed down. He was on daily acid suppression therapy at this time. He denied regurgitation, heartburn, acid water brash, cough, or presenting to emergency room for food impaction. He underwent double contrast esophagram that revealed a possible early Zencker's diverticulum and esophageal web. Subsequent upper endoscopy revealed a normal appearing upper and middle third of the esophagus as well as Barrett's esophagus. There was no endoscopic evidence of stenosis, web or Zencker's diverticulum. Pathology of proximal esophagus revealed increased number of intraepithelial lymphocytes and rare granulocytes predominantly in the peripapillary fields. Given the patient's symptoms of dysphagia and intraepithelial lymphocytosis,this was considered to represent lymphocytic esophagitis. He was continued on a proton pump inhibitor twice per day and started on swallowed fluticasone. After 2 months of therapy, he describes an improvement in symptoms though still has occasional mild dysphagia to solids. Despite recently being diagnosed with increasing frequency, the clinical significance of LE, its treatment, and natural history remain poorly understood. Prospective studies are needed to help us better understand this condition.