Esophagus

• Uncommon esophageal histologic pattern of injury related to different etiologies (Am J Surg Pathol 2022;46:e55, Ann N Y Acad Sci 2018;1434:185)
• Controversial diagnosis as a new distinct disease rather than a pattern of injury associated with more prevalent conditions (Am J Surg Pathol 2022;46:e55)
• More common in older women and patients with underlying immunologic abnormalities (Dig Dis Sci 2021;66:3976, Am J Surg Pathol 2022;46:e55)
• Gastroesophageal reflux disease (GERD), Crohn's disease, dysmotility, achalasia and medication induced esophagitis are some of the underlying conditions associated with lymphocytic esophagitis pattern of injury (Am J Surg Pathol 2022;46:e55)

• Several conditions and diseases are associated with this pattern of injury, from autoimmune diseases such as Crohn's, rheumatoid arthritis, dysmotility disorder (achalasia) to medication effect (Dig Dis Sci 2021;66:3976)

• 28 year old woman with polyvalent sensitization to food and inhalant allergens presented with intermittent dysphagia (Allergy Asthma Clin Immunol 2021;17:56)
• 66 year old woman complaining of dysphagia for several weeks with the loss of ability to swallow solid foods (Cureus 2022;14:e30300)
• 71 year old man with a medical history of squamous cell carcinoma of the tongue treated with external beam radiation 17 years ago presented with dysphagia (Cureus 2018;10:e2153)

Contributed by Omar Aljuboori, M.B.B.S.

Contributed by Monica T. Garcia-Buitrago, M.D., Omar Aljuboori, M.B.B.S. and @RaulSGonzalezMD on Twitter

• Gastroesophageal reflux disease (GERD):
  • Histologic features that are associated with GERD include inflammatory cell infiltrates and classically eosinophils
  • Basal cell hyperplasia with elongated vascular papillae and esophageal spongiosis
• Candida esophagitis:
  • These patients are usually immunocompromised
  • On endoscopy, there are visible white plaques that can be scraped off easily from the underlying mucosa
  • Neutrophilic infiltration is seen in biopsy along with fungal pseudohyphae in sloughed epithelial debris or invading intact squamous epithelium perpendicularly
• Radiation esophagitis:
  • Acute postradiation esophagitis usually shows mucosal necrosis and neutrophilic infiltration
  • In chronic esophagitis, there is submucosal fibrosis, capillary telangiectasia and vascular hyalinization
• Esophageal lichen planus:
  • On endoscopy, mucosal denudation, trachealization and hyperkeratosis are seen; esophageal stenosis may occur
  • Prominent band-like lymphocytic infiltrate involving the interface of lamina propria and epithelium, intraepithelial lymphocytes and dyskeratotic keratinocytes (Am J Surg Pathol 2013;37:1889)
  • Direct immunofluorescence shows diagnostic globular IgM deposits and fibrinogen deposits along the basement membrane zone
• Esophageal graft versus host disease (GVHD):
  • History of hematopoietic stem cell or lymphocyte rich transplant
  • On endoscopy: esophageal webs or strictures in upper or mid third of the esophagus in chronic GVHD
  • Intraepithelial lymphocytosis, basilar vacuolization, epithelial apoptosis and necrosis in severe disease (Best Pract Res Clin Haematol 2008;21:251)

A 60 year old woman underwent an upper endoscopy for dysphagia. Endoscopy revealed stricture in the mid esophagus. In addition to the findings pictured, no neutrophilic / eosinophilic infiltrate was present. What is the most probable diagnosis?

1. Candida esophagitis
2. Gastroesophageal reflux disease (GERD)
3. Lymphocytic esophagitis
4. Radiation esophagitis

C. Lymphocytic esophagitis. The presence of increased lymphocytic infiltrates, esophageal swelling and absence of neutrophilic and eosinophilic infiltrate point towards the diagnosis of lymphocytic esophagitis. Answer B is incorrect because eosinophilic and neutrophilic infiltrates associated with basal epithelial changes are characteristic of gastroesophageal reflux disease (GERD). Answer A is incorrect because neutrophilic infiltration along with fungal pseudohyphae in sloughed epithelial debris is a hallmark of Candida esophagitis. Answer D is incorrect because radiation esophagitis is usually associated with mucosal necrosis and marked neutrophilic infiltration.

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Reference: Lymphocytic esophagitis

A 71 year old man with a known history of squamous cell carcinoma of the tongue treated with external beam radiation 17 years prior, presented to the clinic for esophagogastroduodenoscopy (EGD) with dilation for esophageal strictures. His only complaint at this time was dysphagia. A biopsy was taken and showed the findings above. Which of the following are characteristic features of lymphocytic esophagitis?

1. Basal cell hyperplasia, spongiosis and elongated papillae with intraepithelial lymphocytes can be seen but are accompanied by eosinophils and rare neutrophils
2. Intraepithelial lymphocytosis, basilar vacuolization, epithelial apoptosis and necrosis with a history of hematopoietic stem cell transplant
3. Intraepithelial lymphocytosis, epithelial damage and paucity of granulocytes
4. Prominent band-like lymphocytic infiltrate involving the interface of lamina propria and epithelium, intraepithelial lymphocytes and dyskeratotic keratinocytes

C. Intraepithelial lymphocytosis, epithelial damage and paucity of granulocytes. The presence of lymphocytic infiltrate, esophageal swelling and absence of neutrophilic and eosinophilic infiltrate are the clinical features of lymphocytic esophagitis. Answer D is incorrect because these are the features of esophageal lichenoid planus. Answer B is incorrect because these are the features of graft versus host disease (GVHD). Answer A is incorrect because these are the features of gastroesophageal reflux disease (GERD).

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Reference: Lymphocytic esophagitis

Which of the following stains highlights most of the cells in lymphocytic esophagitis?

1. CD3
2. CD20
3. CD68
4. CD138

A. CD3. CD3 stain identifies T cells, increased in lymphocytic esophagitis cases. Answer B is incorrect because CD20 stain shows rare B cells in lymphocytic esophagitis. Answer C is incorrect because CD68 stain is expressed in histiocytic and monocytic cells. Answer D is incorrect because CD138 stain is expressed in plasma cells.

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Reference: Lymphocytic esophagitis