An Unusual Etiology of Dysphagia in a Patient with Known Eosinophilic Esophagitis

Abstract

Purpose: The natural history of eosinophilic esophagitis (EE) is poorly understood. Dysphagia, odynophagia, retrosternal chest pain, and episodes of food impaction are typical presenting signs and symptoms. Recurrence is common, even after initial response to inhaled corticosteroids and recurrent symptoms are often assumed to represent an exacerbation of EE. We discuss a patient with EE who presented with an unusual treatment-related complication, initially misdiagnosed as an exacerbation of EE. A 32-year-old woman with known eosinophilic esophagitis presented with severe odynophagia and dysphagia to liquids and solids of 2 days duration. Prior to the onset of symptoms, the EE was well controlled on fluticasone 220 mcg 1 puff twice daily. The pain was retrosternal and sharp in nature. She reported an episode of upper respiratory infection 1 week prior to admission. Esophagogastroduodenoscopy revealed severe esophagitis with linear white exudates in the mid to distal esophagus. Biopsies and brushings were performed. She was treated with fluconazole 100 mg daily for presumed fungal esophagitis and discharged the next day with mild to moderate improvement in symptoms. She returned to the hospital the next day with severe odynophagia and dysphagia. Although biopsies were still pending, no fungal elements were seen on the potassium hydroxide preparation. Worsening of her symptoms prompted the addition of intravenous solumedrol 125 mg daily for suspected severe EE. A hypoallergenic diet was also started. The following day the biopsies revealed extensive fibro purulent exudates, ulceration and histologic findings consistent with herpes esophagitis. Steroids were immediately stopped and she was placed on intravenous acyclovir 1 gram every 8 hours for 4 days. An HIV test was negative. She experience relief within 48 hours of antiviral therapy and was symptom free on discharge. She finished a 7-day course of acyclovir and has been symptom free in follow up. Herpes esophagitis is well described in immunocompromised and immunocompetent patients and presents with similar symptoms as EE. This case illustrates that herpes esophagitis is a potential complication of swallowed steroid treatment for EE and should be considered in the differential diagnosis of patients with known EE and recurrent symptoms.