Nimrah Bader, MD
University of Oklahoma Health Sciences Center, Oklahoma City, OK
Introduction: Acute Esophageal Necrosis (AEN) is an uncommon clinical entity characterized by necrosis of the esophagus which is visualized as a circumferential black appearing esophagus during an endogastrodudoenoscope (EGD). Several factors are thought to be behind the tissue injury including hypoperfusion in low flow states, persistent exposure to gastric contents and impaired mucosal defense barriers. In this report, we present a case of black esophagus in a patient with disseminated coccidioidomycosis.
Case Description/Methods: A 42 year-old-man with prior history of untreated HIV, HCV, cirrhosis and polysubstance abuse presented with abdominal pain, fatigue and weakness for four days. His exam was remarkable for a cachectic appearance and tender distended abdomen. He was initially treated for SBP. A diagnostic paracentesis was done which revealed hazy yellow fluid. The fluid analysis was remarkable for WBC 2580, 42% PMNs and 25% Eosinophils. The fluid culture had growth of coccidioides immitits. He was treated with Amphotericin B. He had a prolonged hospital course which was notable for HSV labialis and pneumonitis, Ogilve’s syndrome. On Day 5 his course was complicated by an iatrogenic pneumothorax following chest tube insertion, necessitating mechanical ventilation. One week after extubation, he developed hematemesis. The GI service was consulted and an EGD was done which revealed circumferential ulcerated esophagitis involving the whole length of the esophagus.
Discussion: AEN is an uncommon finding with prevalence of 0.001 to 0.2% as seen in a retrospective endoscopy review. Its etiological basis is multifactorial but has popularly been attributed to ischemic injury during low flow states and gastric outlet obstruction which overwhelm the mucosal protection of the esophagus. Other factors have also been associated with AEN such as antibiotics and concurrent infections (Candida albicans, Cytomegalovirus, Herpes virus, Klebsiella pneumoniae). On literature review there is no known association on coccidioidomycosis and AEN.
After visualizing AEN on EGD, he was treated with high dose proton pump inhibitors, anti-reflux measures and kept NPO. IV fluids and packed red blood cell transfusions were done as supportive measures. Treatment is focused on correcting the underlying disease. Despite treatment of his fungal infection, the patient did poorly because of his infectious burden and multiple in-hospital complications. He elected to go home with hospice.
Citation: Nimrah Bader, MD. P1233 - HEMATEMESIS IN VALLEY FEVER: A CASE OF BLACK ESOPHAGUS. Program No. P1233. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.