S3543 Esophageal Parakeratosis? You GERD Be Kidding!

Abstract

INTRODUCTION: Esophageal parakeratosis is an atypical finding on histology with limited data available. On microscopy it is characterized by superficial, compact squamous epithelium with retained pyknotic nuclei. References describe parakeratosis in various clinical settings such as candidiasis, vitamin B12 and zinc deficiencies, esophageal lichen planus and ethanol exposure in adults. To our knowledge, based on a PubMed Search, this condition has never been reported in children. We describe a child with esophageal parakeratosis with history of reflux symptoms and recent coin ingestion. CASE DESCRIPTION/METHODS: An 8-year-old boy with a history of regurgitation presented to the emergency room with dysphagia after swallowing a penny earlier that day. Chest X-ray revealed a discoid metallic foreign body lodged in the mid esophagus. During upper endoscopy the coin was located in the mid esophagus and retrieved easily. There was an erosion at the site of the penny lodgment and furrowing of the distal esophagus. Biopsies were obtained from the distal esophagus and mid esophagus, distal to the site of coin lodgment. On histological examination of the mid esophageal biopsies, there was mild reactive esophageal squamous mucosa with focal superficial erosion, focal parakeratosis, mild mixed inflammation and vascular congestion without evidence of eosinophilic esophagitis. Based on the pathology, he was diagnosed with gastroesophageal reflux disease (GERD) esophagitis. He was treated with a proton pump inhibitor for 3 months with clinical resolution of reflux symptoms. A 3-month follow-up endoscopy revealed mild edematous mucosa in the distal esophagus without furrowing, ulcers or erythema. Histopathology of the proximal and distal esophagus revealed persistence of minimal reactive esophageal mucosa, with vascular congestion and minimal chronic inflammation but with no parakeratosis. DISCUSSION: Esophageal parakeratosis is often a non-specific histological finding. Based on the clinical history, the resolution of esophageal parakeratosis on repeat biopsy in an area distal to the coin lodgment, along with subtle findings of esophagitis after PPI therapy, led us to believe that the parakeratosis was a manifestation of GERD. It is unlikely that these changes are secondary to a blunt foreign body (coin) reaction in such a short window of time. Clinicians should be aware that esophageal parakeratosis may be associated with GERD.