S3547 Lymphocytic Esophagitis: An Unlikely Mimicker of Gastroesophageal Reflux Disease in the COVID-19 Era

Abstract

Introduction: Lymphocytic esophagitis (LE) is a recently-recognized disease entity characterized by peripapillary chronic inflammation with an endoscopic appearance resembling Eosinophilic esophagitis (EoE). The condition is characterized by esophageal intraepithelial lymphocytosis accompanied by low granulocyte count and spongiosis. Rarely observed in clinical patients, testing for LE is seldom performed and its pathology remains poorly-understood. We present a case report of a patient with prior normal endoscopic appearance who developed severe LE 6 months post SARS-CoV-2 (COVID-19) infection. Additionally, the goal of this case report is to contribute to the limited information about LE with regards to symptoms, signs and endoscopic appearance. Case Description/Methods: A 60-year-old African American gentleman with a history of gastroesophageal reflux disease (GERD), well managed on pantoprazole 40 mg once daily for 3 years who presented with worsening reflux symptoms and regurgitation six months post SARS-CoV-2 infection. He did not have severe respiratory illness secondary to COVID-19 infection. An Esophagogastroduodenoscopy (EGD) was performed, and revealed longitudinal furrowing and white plaque throughout the esophagus suggestive of EoE. These results differed from the normal EGD performed 2 years prior. Esophageal pathology from the mid and distal esophagus displayed lymphocytosis coupled with decreased neutrophil and eosinophil counts consistent with severe lymphocytic esophagitis. Spongiosis was also observed and no fungal components or malignancies were reported. Patient was advised to increase proton pump inhibitors (PPI) twice daily for treatment, and symptoms continue to be monitored. Discussion: LE is a rare disease with limited available knowledge. While the patient’s older age aligns with the established range for this condition, his race and sex deviate from the white, female demographic predominantly associated with LE. We raise the possibility of COVID-19 triggering manifestation of lymphocytic infiltration in the esophagus causing GI symptoms in this patient. The symptoms for this occurrence remained subtle and were confined to the patient’s complaints of heartburn. SARS-CoV-2 changed how we practice medicine in many ways. This case highlights the need to be more vigilant and keep LE in the differential diagnosis even for common diseases like GERD. Our patient did well by increasing PPI to twice daily for two months in this setting.Figure 1.: A. Pre-COVID-19 EGD showing normal Esophagus B & C. Post-COVID-19 EGD showing longitudinal furrows & microabscesses D, E, & F. Post-COVID-19 pathology showing lymphocytic infiltration and spongiosis throughout.