Esophagitis Resembling Allergic Contact Dermatitis
Esophagitis Resembling Allergic Contact Dermatitis
Lymphocytic esophagitis (LE) is characterized by intraepithelial lymphocytes (IELs) and spongiosis, resembling contact dermatitis. LE has been defined as high numbers of IELs and no or rare granulocytes and was found in young patients and in association with Crohn disease (CD). We reviewed the medical records of 42 LE cases. Cases were divided into severe (IELs in interpapillary and peripapillary fields) and mild (IELs in peripapillary fields) LE. The control group included specimens from 34 consecutive esophageal biopsy cases. Mean ages were similar (LE, 44 years; control subjects, 43 years). CD was present in 5 LE cases (12%) and 1 control case, an insignificant difference. Of patients with LE, 14 (33%) had an allergy; 11 (26%), gastroesophageal reflux disease (GERD); 4< (10%), Helicobacter pylori gastritis; and 18 (43%), dysphagia. No differences were found in clinical features between LE and control cases, except GERD was less common in severe LE (6/30 [20%]) than in control cases (17 [50%]). No patient with LE had celiac disease. No medications were common among LE cases. Patients with LE are statistically no more likely than control subjects to have CD. We found no association between LE and any clinical condition or symptom. Based on sequential biopsies in 7 patients, LE seems to be a chronic disease.
Intraepithelial lymphocytosis of the esophagus has been studied to a limited extent in the context of specific diseases. Wang et al found that numbers of intraepithelial lymphocytes (IELs) were increased in patients with reflux esophagitis compared with patients with normal esophageal biopsy findings, but the increase was not statistically significant. Thus, they concluded that IELs could not be used as an independent marker of reflux esophagitis. Resnick et al examined the cytotoxic potential of intraepithelial T lymphocytes in the esophagus and found that numbers of cytotoxic T cells weresignificantly increased in esophageal biopsy specimens with reflux or Candida esophagitis.
Rubio et al were the first to examine IELs in the esophagus more generally. Their study included 20 patients whose esophageal biopsy specimens had increased numbers of IELs in peripapillary fields and no more than rare granulocytes. Clinical histories and endoscopic findings of these patients were compared with those of a control population consisting of 61 patients with biopsies revealing some form of esophagitis (the majority with reflux esophagitis, but a few with Candida or postradiation esophagitis) with both IELs and granulocytes. Of the 20 patients with lymphocytic esophagitis (LE), 11 (55%) were 17 years or younger. Of these 11 pediatric patients, 7 (64%) had Crohn disease. Of the 9 adult patients with LE, only 1 had Crohn disease. Twenty percent had symptoms of gastroesophageal reflux disease (GERD), and 10% had celiac disease. Based on these findings, Rubio et al raised the possibility that LE might be a manifestation of Crohn disease.
Esophageal biopsy specimens with significant intraepithelial lymphocytosis are often also spongiotic, resembling acute spongiotic dermatitis, such as allergic contact dermatitis, irritant contact dermatitis, and atopic dermatitis. In these dermatitides, the epidermis is of normal thickness and spongiotic, with exocytosis of lymphocytes, and sometimes other inflammatory cells, into spongiotic foci. Papillary edema and superficial perivascular lymphohistiocytic infiltrates are also found in spongiotic dermatitis. It is not known if LE has lamina propria edema that corresponds to the dermal edema present in spongiotic dermatitis because there is usually little lamina propria present in esophageal biopsy specimens. The resemblance of LE to spongiotic dermatitis raises the possibility that there may be an allergic or irritant cause for some cases.
Abstract and Introduction
Abstract
Lymphocytic esophagitis (LE) is characterized by intraepithelial lymphocytes (IELs) and spongiosis, resembling contact dermatitis. LE has been defined as high numbers of IELs and no or rare granulocytes and was found in young patients and in association with Crohn disease (CD). We reviewed the medical records of 42 LE cases. Cases were divided into severe (IELs in interpapillary and peripapillary fields) and mild (IELs in peripapillary fields) LE. The control group included specimens from 34 consecutive esophageal biopsy cases. Mean ages were similar (LE, 44 years; control subjects, 43 years). CD was present in 5 LE cases (12%) and 1 control case, an insignificant difference. Of patients with LE, 14 (33%) had an allergy; 11 (26%), gastroesophageal reflux disease (GERD); 4< (10%), Helicobacter pylori gastritis; and 18 (43%), dysphagia. No differences were found in clinical features between LE and control cases, except GERD was less common in severe LE (6/30 [20%]) than in control cases (17 [50%]). No patient with LE had celiac disease. No medications were common among LE cases. Patients with LE are statistically no more likely than control subjects to have CD. We found no association between LE and any clinical condition or symptom. Based on sequential biopsies in 7 patients, LE seems to be a chronic disease.
Introduction
Intraepithelial lymphocytosis of the esophagus has been studied to a limited extent in the context of specific diseases. Wang et al found that numbers of intraepithelial lymphocytes (IELs) were increased in patients with reflux esophagitis compared with patients with normal esophageal biopsy findings, but the increase was not statistically significant. Thus, they concluded that IELs could not be used as an independent marker of reflux esophagitis. Resnick et al examined the cytotoxic potential of intraepithelial T lymphocytes in the esophagus and found that numbers of cytotoxic T cells weresignificantly increased in esophageal biopsy specimens with reflux or Candida esophagitis.
Rubio et al were the first to examine IELs in the esophagus more generally. Their study included 20 patients whose esophageal biopsy specimens had increased numbers of IELs in peripapillary fields and no more than rare granulocytes. Clinical histories and endoscopic findings of these patients were compared with those of a control population consisting of 61 patients with biopsies revealing some form of esophagitis (the majority with reflux esophagitis, but a few with Candida or postradiation esophagitis) with both IELs and granulocytes. Of the 20 patients with lymphocytic esophagitis (LE), 11 (55%) were 17 years or younger. Of these 11 pediatric patients, 7 (64%) had Crohn disease. Of the 9 adult patients with LE, only 1 had Crohn disease. Twenty percent had symptoms of gastroesophageal reflux disease (GERD), and 10% had celiac disease. Based on these findings, Rubio et al raised the possibility that LE might be a manifestation of Crohn disease.
Esophageal biopsy specimens with significant intraepithelial lymphocytosis are often also spongiotic, resembling acute spongiotic dermatitis, such as allergic contact dermatitis, irritant contact dermatitis, and atopic dermatitis. In these dermatitides, the epidermis is of normal thickness and spongiotic, with exocytosis of lymphocytes, and sometimes other inflammatory cells, into spongiotic foci. Papillary edema and superficial perivascular lymphohistiocytic infiltrates are also found in spongiotic dermatitis. It is not known if LE has lamina propria edema that corresponds to the dermal edema present in spongiotic dermatitis because there is usually little lamina propria present in esophageal biopsy specimens. The resemblance of LE to spongiotic dermatitis raises the possibility that there may be an allergic or irritant cause for some cases.
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