Laryngopharyngeal Lesion Appeared in a Patient With Eosinophilic Esophagitis

Abstract

Question: A 52-year-old woman with eosinophilic esophagitis (EoE) stable on the potassium-competitive acid blocker vonoprazan (VPZ) was presented with a cobblestone-like lesion lying between the hypopharynx and the aryepiglottic fold (Figure A). The lesion was found on esophagogastroduodenoscopy (EGD) performed to examine her newly developed mild hemoptysis. The pharynx and larynx were intact 4 months earlier (Figure B). Chest radiography and sputum test for tuberculosis were negative. Her medical condition included dyslipidemia and urticaria. She did not drink alcohol or smoke cigarettes. For further assessment, she was referred to an otorhinolaryngologist, and subsequently the lesion was biopsied with the use of laryngoscopy under general anesthesia. Histologic evaluation found nuclear enlargement with spongiosis in the epithelium cells (Figure C) and remarkable infiltration of inflammatory cells in the subepithelial layer (Figure D). There was insignificant eosinophilia in the biopsies. p53 immunohistochemical staining showed a few positive epithelial cells (Figure E). In addition, enhanced computed tomography found no lymphadenopathy in the neck. On the basis of the findings, the lesion was diagnosed as possible low-grade dysplasia. From then on, she had been closely monitored, in which both the pharyngo-laryngeal lesion and EoE had not changed for 1 year until both conditions exacerbated with newly developed hoarseness. Esophageal biopsy showed increase in intraepithelial eosinophil counts up to 46 per high-power field (Figure F). For deterioration of EoE, topical corticosteroid (200 μg oral fluticasone twice per day) was added to VPZ. Her symptoms gradually improved, and 2 months later a follow-up EGD found significant improvement in not only EoE but also the pharyngo-laryngeal lesion (Figure G). This unexpected response to the treatment led to histologic reassessment of the lesion.