Scope of drug-induced, infectious and allergic esophageal injury

[Esophageal candidiasis as an indicator condition]

Esophageal candidiasis is the most common infectious disease of the esophagus. The diagnosis is based on gastroscopy, and in many cases, biopsy samples should be taken as well. If we do not know of any risk factors for an immunocompromised condition, it is a mutual responsibility to confirm or exclude any potential chronic disease in the background, thus not just the secondary complication but also the primary disease could be treated. Without this knowledge, in many cases, the correct diagnosis may be delayed for months or even years, which may risk the successful treatment. We present the case of a 58-year-old healthy woman without any chronic disease, who was referred to our clinic with dysphagia. Due to her complaints we performed a gastroscopy, upon which advanced esophageal candidiasis was diagnosed, hence she was started on oral systemic antifungal treatment. Although we could not explore any risk factors, further investigations behind the immunocompromised condition revealed a positive immunoserology test for HIV. The take-home message of our case is that in the case of esophageal candidiasis, the cause of immunosuppression must be searched for, of which HIV serology is crucial. Thanks to the prompt and correct diagnosis, we could start the suitable treatment of the underlying disease. Orv Hetil. 2023; 164(22): 878-880.

Possible Risk Factors for Candida Esophagitis in Immunocompetent Individuals

Background

Candida esophagitis (CE) is a condition typically diagnosed in patients who are immunocompromised. Risk factors leading to the development of CE in immunocompetent patients have not been entirely elucidated. This study set out to identify risk factors associated with the development of CE in immunocompetent patients.

Methods

This study was a single-center retrospective chart review. Patients diagnosed with CE confirmed by endoscopic biopsy or brushings at our hospital between 2007 and 2017 were reviewed. The medical histories, endoscopy reports and pathology results were noted. Abdominal pain, heartburn, dysphagia and odynophagia were the common indications for endoscopy. A total of 241 patients were identified as having been diagnosed with CE by endoscopic brushing or biopsy. Of these patients, 161 were excluded due to the presence of immunocompromising and 80 patients were included who had no underlying immunocompromising conditions.

Results

Eighty patients with CE satisfied the inclusion criteria. The mean age of patients at the time of diagnosis was 39.8 years old (95% CI: 34.9 - 44.7). The incidences in men and women were similar in this study (49% women and 51% men). Of these patients, 56 (70%) (95% CI: 59-80%; P < 0.005) were taking proton pump inhibitors (PPIs). Fifteen patients (19%) had a previous upper endoscopy with evidence of reflux esophagitis, and they were all treated with PPIs and subsequently found to have CE on repeat upper endoscopy with a mean of 21.6 months of PPI treatment. There were 16 (20%) patients without any attributable risk factor and were completely healthy.

Conclusions

CE is an opportunistic infection typically seen in immunocompromised. We report incidence of CE in immunocompetent patients. In our cohort of immunocompetent patients, PPI use was the most common risk factor associated with the development of CE. This could be related to hypochlorhydria resulting from PPI use. However, the cause remains unclear in some patients.

Histomorphological and Immunophenotypic Features of Pill-Induced Esophagitis

The aim of this study was to investigate histomorphological and immunophenotypic features in pill-induced esophagitis. We comparatively evaluated the histomorphological, immunophenotypic features of pill-induced esophagitis vs. reflux esophagitis, as well as clinical information and endoscopic findings. Fifty-two tissue pieces from 22 cases of pill-induced esophagitis, 46 pieces from 20 reflux esophagitis, and 16 pieces from 14 control samples were subjected to immunohistochemistry for inflammatory infiltrates (CD3 for T lymphocyte, CD20 for B lymphocyte, CD56 for NK cell, CD68 for macrophage, CD117 for mast cell) and eosinophil chemotaxis-associated proteins (Erk, leptin, leptin receptor, pSTAT3, phospho-mTOR). As a result, Histomorphology showed that a diffuse pattern of dilated intercellular spaces was more frequently observed in pill-induced esophagitis, while reactive atypia and subepithelial papillary elongation were more often found in reflux esophagitis (P < 0.05, respectively). Interestingly, intraepithelial eosinophilic microabscess, intraepithelial pustule and diffuse pattern of dilated intercellular spaces were observed in 14% (3 cases), 9% (2 cases) and 32% (7 cases) of pill-induced esophagitis, respectively, but in no cases of reflux esophagitis. Regarding intraepithelial inflammatory infiltrates in pill-induced esophagitis, T lymphocytes were the most common cells, followed by eosinophil; 11 and 7 in one x400 power field, respectively. Intraepithelial pSTAT3-positive pattern was more frequently observed in pill-induced esophagitis than in reflux esophagitis, at 45% (10 cases) versus 10% (2 cases), respectively (P < 0.05). Considering the distal esophageal lesion only, intraepithelial pustule, diffuse dilated intercellular spaces and stromal macrophages were more frequently found in distal pill-induced esophagitis, whereas reactive atypia and intraepithelial mast cells in reflux esophagitis (P < 0.05, respectively). In conclusion, diffuse dilated intercellular spaces, intraepithelial eosinophil microabscess, pustule, T lymphocytes, eosinophils, and pSTAT3 positivity can be added to histopathological features of pill-induced esophagitis, other than non-specific ulcer. Besides, distal pill-induced esophagitis may be histopathologically differentiated from reflux esophagitis.

Clinical features of eosinophilic esophagitis: ten Japanese cases

AIM

We studied eosinophilic esophagitis (EE) to clarify the clinical and endoscopic features of a Japanese case series.

METHODS

Records of 10 patients diagnosed with EE at our hospital between May 2010 and December 2011 were examined for age, sex, symptoms, allergic disorder, endoscopic findings, and treatment received. Esophageal wall thickness was measured by endoscopic ultrasonography (EUS).

RESULTS

Patients were seven males and three females with a mean age of 48 years. Symptoms included dysphagia, heartburn, food impaction, and chest pain. Nine patients had a history of allergic diseases. Increased peripheral eosinophil count was observed in one patient whereas increased immunoglobulin E level was observed in eight patients. Endoscopic findings included longitudinal furrows in all patients, mucosal edema in nine patients, loss of vascular pattern in nine patients, white exudates in six patients, cobblestone-like appearance in five patients, and concentric rings in three patients. EUS revealed thickening of the esophageal wall in one patient. Histopathological examination revealed eosinophilic infiltration (≥15 eosinophils/high-powered field) in the esophageal epithelium of all patients. Treatment was required in six patients. Proton pump inhibitor (PPI) therapy was given as the first-line treatment but was ineffective in four patients and effective in two patients. Steroid therapy was given to three patients unresponsive to PPI therapy and was effective.

CONCLUSIONS

EE was common among relatively young men and was associated with allergic diseases. Longitudinal furrows were observed as the most characteristic endoscopic finding. Esophageal wall thickening was not commonly observed by EUS.

What is new in esophageal injury (infection, drug-induced, caustic, stricture, perforation)?

PURPOSE OF REVIEW: We will focus separately on infectious, drug-induced and caustic injury of the esophagus and their possible complications such as stricture and perforation. RECENT FINDINGS: There has been a decrease in opportunistic esophageal infection in HIV-positive patients, in particular candidiasis, which remains an important cause of inpatient charges, length of stay and total hospital costs, and new antifungal therapy are currently explored. As far as drug-induced esophageal injury is concerned, more than 1000 cases of all cases due to nearly 100 different medications have been described during the last 10 years. However, the estimated case frequency is probably much higher and the related literature is of low quality, as cases are reported selectively and stimulated by clustering of cases, newly implicated pills or unusual complications. Finally, in the field of caustic ingestion-related injury, there has been greater understanding of geographical differences in prevalence and more frequently involved substances, choice of optimal timing for endoscopy, relationship between symptoms and severity of lesions and appropriate role of steroids and other therapies, such as the topical application of mytomicin C. SUMMARY: This update covers the most relevant papers published on the three areas of interest during the last year.

Drug-induced esophagitis

Drug-induced esophagitis is being recognized increasingly in the past few years. Since 1970 more than 650 cases have been reported worldwide caused by 30 or more medications. We have reviewed these cases with a view to classifying this disease based on underlying pathological mechanism. Drug-induced esophageal injury tends to occur at the anatomical site of narrowing, with the middle third behind the left atrium predominating (75.6%). The disease is broadly classified into two groups. The first group being transient and self-limiting as exemplified by the tetracycline group induced injury (65.8%). The second is the persistent esophagitis group, often with stricture, with two distinct entities: (i) patients on nonsteroidal anti-inflammatory agents whose injury is aggravated by gastroesophageal reflux (21.8%) (reflux aggravated); and (ii) patients with potasium chloride and quinidine sulphate induced injury (12.4%) (persistent drug injury). Severe esophageal injury has been reported in some women taking biphosphonates as treatment for postmenopausal osteoporosis. Endoscopic findings in such patients with esophageal injury generally suggested a chemical esophagitis, with erosions or ulcerations and exudative inflammation accompanied by thickening of the esophageal wall. Most cases of medication-induced esophageal injury heal without intervention within a few days. Thus, the most important aspect of therapy is to make the correct diagnosis and then to avoid reinjury with the drug. When possible, potentially caustic oral medications should be discontinued.