S4263 Esophageal Lichen Planus: An Underdiagnosed Cause of Dysphagia: A Case Report

Introduction: Lichen planus (LP) is a chronic inflammatory disorder affecting the skin and mucous membranes. Esophageal lichen planus (ELP) is a rare manifestation with malignant potential. This is a case of an elderly woman with a history of mucocutaneous LP who was investigated for progressive dysphagia and was diagnosed with ELP. This case highlights the clinical significance, diagnostic challenges, and therapeutic limitations associated with ELP. Case Description/Methods: A 75-year-old woman with a history of mucocutaneous LP presented with a 1 year history of progressive dysphagia to solids, oral ulcers, heartburn, and epigastric discomfort. She reported episodes of food impaction and decreased taste sensation. Her double contrast esophagogram with intermittent fluoroscopy was normal. Esophagogastroduodenoscopy revealed mucosal plaques in the oropharynx, proximal esophageal stricture, and mucosal inflammation with separation. Biopsies from the proximal esophagus showed esophagitis with parakeratosis, intraepithelial lymphocytosis, and numerous Civatte bodies, consistent with ELP. Viral serologies for Hep C and HIV were negative. She was started on budesonide and nystatin, with initial improvement. However, symptoms recurred on dose tapering, necessitating a more gradual taper. Repeat endoscopy showed persistent proximal narrowing. Surveillance esophagogastroduodenoscopy was scheduled with possible dilation due to persistent symptoms. Discussion: ELP is a rare condition associated with mucocutaneous LP. Hep C and HIV are common associations but are not universally present. ELP presents with nonspecific symptoms like dysphagia, odynophagia, and food impaction. Endoscopic findings include trachealization, mucosal fragility, and strictures. Histologic hallmarks include Civatte bodies and T-cell–predominant infiltrates. ELP may lead to chronic inflammation, fibrosis, and eventual malignant transformation into esophageal squamous cell carcinoma, with TP53 mutations implicated in pathogenesis. Thus, early diagnosis is crucial. Treatment with steroid preparations is effective in most cases however, relapses are common, and long-term management remains a challenge. Serial esophageal dilations may be required but can be complicated by restenosis. In conclusion, ELP is an underrecognized esophageal disorder and should be considered, especially in patients with unexplained dysphagia and mucocutaneous LP due to its premalignant potential. Diagnosis relies on high clinical suspicion, endoscopy, and biopsy. A multidisciplinary approach is needed with further research into targeted therapies.