A 53-year-old man with nocturnal cough undergoes an upper endoscopy with esophageal biopsy. Light microscopy of the tissue specimen shows elongation of the lamina propria papillae with several eosinophils and neutrophils scattered within the squamous epithelium. The patient takes metformin and enalapril for diabetes mellitus and hypertension, respectively. He is started on pantoprazole, and after 2 weeks his cough symptoms resolve. Which of the following was the most likely cause of his symptoms?

Question

A 53-year-old man with nocturnal cough undergoes an upper endoscopy with esophageal biopsy.  Light microscopy of the tissue specimen shows elongation of the lamina propria papillae with several eosinophils and neutrophils scattered within the squamous epithelium.  The patient takes metformin and enalapril for diabetes mellitus and hypertension, respectively.  He is started on pantoprazole, and after 2 weeks his cough symptoms resolve.  Which of the following was the most likely cause of his symptoms?

Quizplus · Accepted Answer

11ec160b_3949_9e23_9249_51d2e5b86aa7_MD0001_00 Gastroesophageal reflux disease (GERD) is a very common condition that usually manifests with heartburn, regurgitation, and dysphagia. However, patients can have extraesophageal symptoms (eg, nocturnal cough, hoarseness) in the absence of heartburn ("silent GERD"). Gastroesophageal junction incompetence is the primary pathophysiologic mechanism responsible for GERD. This incompetence is most commonly caused by excessive relaxation of the lower esophageal sphincter, resulting in the reflux of acidic gastric contents back into the esophagus. Irritation of the esophageal mucosa leads to an inflammatory reaction with mucosal erythema and edema; erosions/ulcerations may develop in severe cases. Characteristic histologic findings include basal zone hyperplasia, elongation of the lamina propria papillae, and scattered eosinophils and neutrophils. (Choice A) Absent esophageal peristaltic movements can be seen with achalasia and systemic sclerosis. The distinctive histopathologic findings of systemic sclerosis involving the esophagus include atrophy of the muscularis with collagenous fibrosis. (Choice B) Eosinophilic esophagitis is an immune/antigen-mediated disease that typically presents with dysphagia and food impaction in atopic adults. It is characterized histologically by numerous superficially located intraepithelial eosinophils, which can help differentiate it from reflux esophagitis. (Choice D) Candida albicans is the most common cause of infectious esophagitis in HIV and immunocompromised patients. Endoscopy typically shows white plaques on an erythematous mucosa, and light microscopy demonstrates pseudohyphae and budding spores embedded in necrotic debris. (Choice E) Herpes simplex virus (HSV) and cytomegalovirus (CMV) are other common causes of infectious esophagitis in immunocompromised patients. HSV usually shows punched-out ulcers on endoscopy with eosinophilic nuclear inclusions on biopsy. In contrast, CMV produces shallow/linear ulcers with nuclear/cytoplasmic viral inclusions. (Choice F) Pill-induced esophagitis is commonly seen with tetracycline antibiotics, potassium chloride, and bisphosphonates. Metformin and enalapril do not cause esophagitis. Educational objective: Gastroesophageal reflux disease is caused primarily by gastroesophageal junction incompetence and can be associated with extraesophageal symptoms (eg, nocturnal cough) in the absence of heartburn ("silent GERD"). Acidic gastric contents irritate the esophageal mucosa, leading to characteristic histologic findings that include basal zone hyperplasia, elongation of the lamina propria papillae, and scattered eosinophils.

A 53-Year-Old Man with Nocturnal Cough Undergoes an Upper Endoscopy