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Figure 1 |
Figure 2 |
Javad Mikaeli MD•, Hossein Nobakht MD, Masoud Sotudeh MD, Reza Malekzadeh MD
Authors’ affiliation: Digestive Disease Research Center, Department of Internal Medicine, Tehran University of Medical Sciences, Tehran, Iran.
·Corresponding authors and reprints: Javad Mikaeli MD, Digestive Disease Research Center, Shariati Hospital, North Kargar Ave., Tehran, Iran. Fax: +98-21-2253635, E-mail: malek@ams.ac.ir.
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29-year-old man was admitted to the hospital with severe retrosternal pain and a fever of three weeks duration. He also had dysphagia, odynophagia, nausea, and epigastric pain, but denied any flu-like symptoms, cough, dyspnea, abdominal pain, diarrhea, recent blood product transfusion, drug consumption, and high-risk behavior.
The only finding on physical examination was a body temperature of 39˚C. Complete blood count (CBC) , erythrocyte sedimentation rate (ESR), creatinine, electrolytes, and serologic tests for cytomegalovirus, herpes simplex virus type I and II, Epstein-Barr virus (EBV), and human immunodeficiency virus (HIV), were all negative Blood, stool, and urine cultures, and PPD skin test were also negative. Chest X-ray (CXR), abdominal computerized tomography (CT) scan, and small bowel transit were unremarkable. Upper GI endoscopy showed multiple small discrete aphthous ulcers with erythematous rim in the distal two-thirds of esophagus. Stomach and duodenum were normal. (Figure 1)
Histological examination of esophageal mucosal biopsy showed severe esophagitis without evidence of viral inclusions.
Colonoscopy revealed aphthous-like lesions in the colon with normal looking mucosa in-between. The biopsy (Figures 1 and 2) of colonic lesions revealed granuloma along with crypt abscess formation.
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Photoclinic Diagnosis: Crohn’s Disease of Esophagus |
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he history presented is compatible with a nonreflux inflammatory process in the esophagus.
Histological examination of esophageal mucosal biopsy revealed severe esophagitis and granuloma formation without evidence of viral inclusions, fungal elements, malignancy, or acid fast bacilli.
Histology of colonic mucosal biopsy showed severe acute and chronic inflammation in lamina propria with granuloma formation, suggestive of Crohn’s disease. Acid fast stain was negative.
Crohn’s disease is becoming a common chronic inflammatory bowel disorder in Iran.1, 2 The lesions in Crohn’s disease can occur in any part of the alimentary tract from the mouth to the anus.
Esophageal Crohn’s disease is rare in adults, occurring in 0.2% to 11.2% of cases. However, it is more frequent in children (up to 43%).1, 2 Nearly all reported cases of esophageal Crohn’s disease had ileal and/or colonic involvement.3, 4
Endoscopically, the most common lesions of esophageal Crohn’s disease
are aphthous ulcers.5 It is important to exclude other causes of
esophageal ulcers before the diagnosis of Crohn’s disease is made, especially
if the patient has esophageal lesions without granulomas.
Colonoscopy
may be helpful in this regard.
Generally, granulomas are accepted as histo-logical proof of esophageal Crohn’s disease, but granulomas of esophageal Crohn’s disease were reported in only 16 (20.8%) of 77 patients reviewed.6
While the most common symptom in esophageal Crohn’s disease is dysphagia, the dominant symptoms in our patient were severe chest pain and fever.
References
1 Malekzadeh R, Varshosaz J, Merat S, et al. Crohn’s disease: a review of 140 cases from Iran. IJMS. 2000; 25: 138 – 143.
2 Shahbazkhani B, Mohamadnejad M, Malekzadeh R, et al. Coeliac disease is the most common cause of chronic diarrhoea in Iran. Eur J Gastroenterol Hepatol. 2004; 16: 665 – 668.
3 Ramaswamy K, Jacobson K, Jevon G, Israel D. Esophageal Crohn disease in children: a clinical spectrum. J Pediatr Gastroenterol Nutr. 2003; 36: 454 – 458.
4 Decker GA, Loftus EV Jr, Pasha TM, Tremaine WJ, Sandborn WJ. Crohn's disease of the esophagus: clinical features and outcomes. Inflamm Bowel Dis. 2001; 7: 113 – 119.
5 Rudolph I, Goldstein F, DiMarino AJ Jr. Crohn's disease of the esophagus: three cases and a literature review. Can J Gastroenterol. 2001; 15: 117 – 122.
6 Ohta M, Konno H, Kamiya K, et al. Crohn's disease of the esophagus: report of a case. Surg Today. 2000; 30: 262 – 267.