S4360 Impact of Rheumatoid Arthritis Treatment With Methotrexate and Low-Dose Prednisone on PPI-Refractory Lymphocytic Esophagitis: A Case Report

Introduction: Lymphocytic esophagitis (LyE) is an emerging and poorly understood inflammatory condition, presenting with dysphagia and atypical chest pain. Histologically, LyE is defined by dense infiltration of >20 peripapillary intraepithelial lymphocytes per high-power field with the absence or paucity of granulocytes, e.g., neutrophils and eosinophils. The natural history of LyE and its effective treatments remain poorly characterized. We previously described the beneficial therapeutic effects of oral viscous budesonide (OVB) in proton-pump inhibitor (PPI)-refractory LyE. We present herein a case of PPI-refractory LyE, controlled with OVB, that improved optimally following the initiation of systemic treatment of rheumatoid arthritis (RA) with the disease-modifying antirheumatic drug (DMARD), methotrexate, along with low-dose prednisone. Case Description/Methods: An 81-year-old woman with a past medical history of irritable bowel syndrome, hiatal hernia, oral lichen planus, lymphocytic colitis, Lyme disease, osteoarthritis, anxiety and depression was diagnosed with LyE following solid-food dysphagia and globus sensation. Esophagogastroduodenoscopy showed diffuse esophageal narrowing, pallor, edema, decreased vascularity, multiple rings, webs and distal strictures status post dilation to 15 mm. Pan-esophageal biopsies confirmed LyE with >25 intraepithelial lymphocytes/high-power field. Despite high-dose PPI, LyE progressed, requiring serial dilations. OVB was initiated at 2 mg twice daily with clinical, endoscopic, and histologic improvement, and tapered to 0.5 mg twice daily as maintenance. After 1 year on OVB, with intermittent low-dose PPI, repeat esophagogastroduodenoscopy showed continued remission with improved vascularity, decreased edema, mild rings, and 2 focal strictures dilated to 18 mm. Following a new diagnosis of RA, methotrexate with low-dose prednisone was initiated. On RA treatment, low-dose PPI, and low-dose OVB, serial esophagogastroduodenoscopies were performed every 6 months over the next 2 years, with superior endoscopic and histologic improvement. OVB was discontinued after 1 year of RA therapy. On DMARD for RA treatment, LyE remained in superior deep remission. Discussion: Definitive treatment for LyE has not been established, although off-label use of PPI and topical corticosteroids, e.g., OVB, has been described with variable success. Relative to OVB, which improved PPI-refractory LyE in our patient moderately, treatment with the DMARD, methotrexate, and low-dose prednisone for concomitant RA appeared to be superior for LyE, serving as a basis for future studies.