S4339 Lymphocytic Esophagitis With Concomitant Esophagitis Dissecans Superficialis: A Rare Overlap in an Elderly Woman With Dysphagia

Introduction: Lymphocytic esophagitis (LyE) is a rare, chronic inflammatory condition characterized histologically by intraepithelial lymphocytosis with minimal granulocytosis. The estimated incidence is 0.1% and is more commonly seen in women in later decades of life. Esophagitis dissecans superficialis (EDS) is an uncommon desquamative disorder defined by mucosal sloughing with minimal inflammation. Both conditions may present with chest discomfort, dysphagia, or dyspepsia. These 2 conditions are rarely seen concurrently and may present with overlapping clinical and endoscopic features, complicating diagnosis. Case Description/Methods: We report the case of an elderly woman with a medical history significant for psoriasis on risankizumab, hyperlipidemia on atorvastatin, and gastroesophageal reflux disease who presented with dysphagia refractory to pantoprazole 40 mg twice daily. Esophagogastroduodenoscopy at this presentation revealed extensive mucosal sloughing in the distal esophagus with normal appearance of underlying mucosa and erythematous changes of the gastric antrum and prepyloric region. Random biopsies taken from the distal esophagus demonstrated extensive intraepithelial lymphocytes with necrosis and up to 20 eosinophils per high-power field admixed with superficial necrotic eosinophilic squamous epithelium between viable reactive squamous epithelium. She was given a clinical diagnosis of lymphocytic esophagitis with EDS. The patient was initiated on budesonide 1 mg once daily oral solution with pantoprazole. Discussion: This case illustrates a rare overlap between LyE and EDS. LyE is associated with autoimmune conditions (including IBD), gastroesophageal reflux disease, esophageal motility disorders, tobacco use, and medications such as aspirin and statins. Risk factors for EDS include autoimmune conditions, NSAID/bisphosphonates, and chemical irritants including tobacco. Our patient has several risk factors and falls within the typical demographic range. The endoscopic findings of LyE can mimic eosinophilic esophagitis with mucosal edema, linear furrows, and rings. Although at a diagnostic level for eosinophilic esophagitis, in this case the eosinophils were suspected to be secondary given the dense lymphocytic infiltration. This case underscores the importance of thorough histopathologic evaluation of dysphagia with nonspecific or overlapping endoscopic findings. Recognizing mixed histologic patterns is critical for accurate diagnosis and tailored therapy.