Wayne State University School of Medicine Detroit, MI, United States
Noemi Garg, BS1, Adarsh K. Varma, MD2, Syed-Mohammed Jafri, MD2 1Wayne State University School of Medicine, Detroit, MI; 2Henry Ford Health System, Detroit, MI
Introduction: We present a case of esophageal parakeratosis, in a patient with persistent acid reflux, to further our understanding of this condition.
Case Description/Methods: A 59-year-old female with a history of biliopancreatic diversion with duodenal switch (1997) reports to the clinic with persistent acid reflux failing a therapeutic trial of omeprazole-sodium bicarbonate (40mg by mouth daily). The patient denies a history of nausea, vomiting, dysphagia, abdominal pain, or weight changes. The patient is taking high potency multivitamins twice a day and vitamin B12 supplements daily. No history of ethanol exposure or micronutrient deficiencies were noted. Esophagogastroduodenoscopy showed patchy, mild inflammation of the gastric antrum with white nummular lesions in the lower esophagus. Biopsy of the gastric antrum showed mild chronic gastritis and focal intestinal metaplasia. Biopsy of the distal esophagus showed focally-active neutrophilic esophagitis with parakeratosis. The care team recommends repeating upper gastrointestinal (GI) endoscopy in one year to reassess the condition, to obtain gastric mapping for gastric intestinal metaplasia, and continuing proton-pump inhibitor therapy to manage gastroesophageal reflux disease (GERD). The patient was started on sucralfate (1mg by mouth 4 times daily as needed), staggered 2 hours apart from proton pump inhibitor therapy, for breakthrough symptoms.
Discussion: Esophageal parakeratosis is a rare finding with limited case reports in medical literature. It is often diagnosed after performing a biopsy on esophageal samples and is characterized as an incomplete keratinization of esophageal squamous epithelium. Esophageal parakeratosis often mimics esophageal dysplasia and should be considered in the differential diagnosis when patients persistently present with flat elevated lesions in their distal esophagus. Previous case studies found an association between esophageal parakeratosis and zinc, riboflavin deficiency, vitamin B12 deficiency, ethanol exposure, and GERD. Studies done in animal models showed a direct relationship between zinc deficiency and esophageal keratinization followed by improvement with zinc repletion. However, the malignant potential of esophageal parakeratosis and the role of micronutrient deficiencies in its development are still not understood. More case reports are needed to help elucidate the clinical significance of this condition, and if surveillance for esophageal dysplasia should be employed in this patient population.
Noemi Garg, BS1, Adarsh K. Varma, MD2, Syed-Mohammed Jafri, MD2. P2440 - A Unique Case of Esophageal Parakeratosis Presenting as Persistent Acid Reflux, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.