S4410 A Rare Case of Esophageal Parakeratosis Found During Endoscopic Evaluation of Dysphagia

Introduction: Esophageal parakeratosis is a relatively rare finding on upper gastrointestinal endoscopy of unclear clinical significance characterized by incomplete keratinization of squamous epithelium resulting in retention of nuclei in superficial squamous epithelium. It can mimic neoplastic and infectious processes and has been associated with micronutrient deficiencies (zinc, vitamin B12, riboflavin), tylosis, alcohol use disorder. We present a case of esophageal parakeratosis found during evaluation for dysphagia. Case Description/Methods: Seventy-six-year-old man with past medical history of gastroesophageal reflux disease (GERD), vitamin B12 deficiency and macrocytosis in setting of alcohol use dependence, atrial fibrillation on daily low dose aspirin, underwent esophagogastroduodenoscopy for further evaluation of dysphagia particularly to solid foods and intermittently to pills. Continuous white linear plaques starting from proximal to distal esophagus were noted during endoscopy, which endoscopist diagnosed as parakeratosis. Esophageal biopsies with special stain for Alcian Blue and Perioidic Acid-Schiff confirmed this finding and ruled out dysplasia/neoplastic process. Due to gastritis for which gastric biopsies were negative for H. pylori and gastric intestinal metaplasia and known history of GERD, patient was started on omeprazole 20 mg twice daily and reported improvement in dysphagia symptoms. Discussion: Esophageal parakeratosis is a relatively rare finding on upper gastrointestinal endoscopy of unclear clinical significance characterized by incomplete keratinization of squamous epithelium resulting in retention of nuclei in superficial squamous epithelium. Although this is largely considered a benign condition classically associated with micronutrient deficiencies particularly with alcohol use disorder, and no surveillance recommendation has been established, there have been associations with esophageal malignancy. Furthermore, it can mimic neoplastic and infectious processes hence careful examination is recommended to not miss a more sinister process. Our patient reported improved dysphagia after treatment of his GERD and gastritis with omeprazole 20 mg twice daily. There are some case reports of this being found during evaluation for pyrosis. Additionally, he had a history of B12 deficiency and alcohol use disorder both of which are associated this and there is a case report of esophageal dysphagia in setting of parakeratosis improving with B12 supplementation.