University of Nebraska Medical Center Omaha, NE, United States
Lauren Keim, MD, Thoetchai Peeraphatdit, MD University of Nebraska Medical Center, Omaha, NE
Introduction: We present a case of a young female patient with chronic dysphagia found to have an ulcerative esophageal mass. Pathology surprisingly demonstrated granulomatous inflammation. This case highlights the diagnostic challenges of gastrointestinal granulomatous disease mimicking esophageal malignancy.
Case Description/Methods: A 22-year-old female presented with five years of progressive dysphagia to solid foods. Past medical history was significant for papillary thyroid carcinoma status post thyroidectomy two years prior (T1bN0M0) and psoriasis treated with topical corticosteroids. Upper endoscopy revealed a 2 cm ulcerated, partially obstructive mass in the lower third of the esophagus, Figure. Biopsy demonstrated granulomatous inflammation without neoplastic changes. Grocott’s methenamine silverstain (GMS) and Steiner stain showed small irregular structures in the granulomas. Acid-fast bacilli (AFB) stain was negative. A repeat upper endoscopy with endoscopic ultrasound (EUS) revealed an additional hypoechoic lesion in the proximal esophagus. EUS-guided fine needle aspiration of this lesion and repeat biopsy of the ulcerative mass both showed non-necrotizing granulomas without eosinophilia. GMS and AFB stains resulted negative. Colonoscopy with ileal and random biopsies was unremarkable. Interferon-gamma release assay, Treponema pallidum antibody, Legionella urine antigen, H.pylori stool antigen, and Histoplasma urine and serum antigens resulted negative. Computed tomography (CT) scan of the chest showed 1.1 cm and 0.6 cm right lower lobe pulmonary nodules and an enlarged right hilar node at 1.9 x 1.2 cm. The patient is awaiting pulmonary nodule biopsy given high suspicion for sarcoidosis.
Discussion: Granulomatous disease of the gastrointestinal tract can be seen in infections, Crohn’s disease, sarcoidosis, malignancy, and immunodeficiency syndromes. The clinical context, morphology of the granuloma, and specialized stains for organisms can support a suspected diagnosis. Necrotizing granulomas are most frequently implicated in M. tuberculosis infection, while non-necrotizing granulomas have a wider differential diagnosis which includes infection, autoimmune disease, toxins, and medications. Sarcoidosis is suspected in our patient given the clinical history, negative diagnostic workup for infections and Crohn’s disease, and CT chest findings. In patients found to have gastrointestinal granulomas, a broad differential should be considered with thorough evaluation to obtain definitive diagnosis.
Figure: Ulcerated mass in the lower third of the esophagus
Lauren Keim indicated no relevant financial relationships.
Thoetchai Peeraphatdit indicated no relevant financial relationships.
Lauren Keim, MD, Thoetchai Peeraphatdit, MD. P1381 - Granulomatous Esophageal Disease Mimicking Esophageal Malignancy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.