S5138 Sarcina Esophagitis Complicating a Large Hiatal Hernia

Introduction: Sarcina ventriculi is a gram-positive anaerobic bacterium that has emerged as a rare, potentially deadly cause of upper gastrointestinal tract disease in humans. Only 66 cases have been identified as of 2022. Sarcina has been associated with rare cases of emphysematous gastritis and perforation. It has been specifically linked to conditions that alter gastric motility, such as gastroparesis and obstruction. We present a case of Sarcina complicating a large hiatal hernia, supporting the association with dysmotility and food stasis. Case Description/Methods: A 62-year-old man with past medical history of end stage renal disease and human immunodeficiency virus (undetectable viral load) presented with dysphagia to solid foods for 1 month and 1 episode of coffee ground emesis during an inpatient evaluation for hypotension secondary to sepsis. Upper endoscopy demonstrated deep esophageal ulcers, patchy areas of white plaques, and a 6 cm hiatal hernia. Diffuse, mild erythema was seen in the gastric body and cardia. The duodenum appeared normal. Biopsies from the esophagus revealed a fibrinopurulent exudate and bacterial forms suggestive of Sarcina spp. Esophageal biopsies were negative for candida. Gastric biopsies showed focal gastritis and was negative for Sarcina and H. pylori. Computed tomography (CT) of the abdomen confirmed the presence of the large hiatal hernia. The patient was treated with oral amoxicillin and metronidazole for 7 days with eventual resolution of symptoms. The patient was lost to follow up, so repeat endoscopy was not completed. Discussion: It is postulated that Sarcina is found in settings of decreased motility because stasis of food gives the bacteria access to fermentable carbohydrates. In 50% of cases of esophageal Sarcina, food was also found in the esophagus. Due to the rarity of Sarcina, specific guidelines on treatment have not been established. Given the association with severe complications like emphysematous gastritis, identification of Sarcina on biopsy should prompt treatment, as well as an investigation into underlying dysmotility. Treatment with antibiotics is effective, and important to avoid disease complications. Most literature has focused on impaired gastric dysmotility as a risk factor for Sarcina related disease, but other conditions that promote food stasis in the esophagus, such as hiatal hernias, may play a role in the pathogenesis of Sarcina related disease.