This is the oesophagus of a 45 yr old woman 3 weeks into induction chemotherapy for AML when she develops retrosternal pain and fever. Treatment with meropenem, ambisome, itraconazole, aciclovir and intravenous omeprazole is started with improvement of symptoms. This is the lower third of her oesophagus.
WHAT IS THE MOST LIKELY DIAGNOSIS?
a) reflux oesophagitis
b) infective oesophagitis
c) squamous cell carcinoma
e) infiltration by myeloid cells
An unusual appearance to the squamous portion of the oesophagus! Lower down, the appearances were unremarkable and healing reflux oesophagitis was therefore unlikely. Stains for fungi and immunohistochemistry for CMV were both negative.
However, there were some multinucleated squamous cells and after a long search by our histopathologist, a couple of likely viral inclusions were found. This is a resolving herpetic oesophagitis ! Resolving because the patient had already been on aciclovir for a week when the endoscopy was done.
Small miracle that our pathologists found traces of the original infection! This is a common issue with immunosuppressed patients. The haematologists are VERY quick to start a broad range of anti-microbial medication, covering fungi, viruses and bacterial pathogens. By the time the endoscopy is done, the original pathogen is usually suppressed to undetectable levels.