SCIENTIFIC
Acute esophageal necrosis in a patient with mild SARS-CoV-2 infection
AUTHORS : Joyce Foryoung , MD 1
Monica Chowdhary , MD 2 Megan Willard , MD 3
1
Internal Medicine Resident , West Virginia University School of Medicine
2
Gastroenterology Fellow , West Virginia University School of Medicine
3
Assistant Professor , West Virginia University School of Medicine
CORRESPONDING AUTHOR : Megan Willard megan . willard @ hsc . wvu . edu
DISCLOSURES : None
ETHICS STATEMENT : Permission obtained from patient
FUNDING : None
CASE PRESENTATION
A 92-year-old male with multiple comorbidities presented with an episode of coffee ground emesis , presumed to be due to an upper gastrointestinal bleed . His only other complaint was fatigue , and he specifically denied any abdominal pain , nausea , vomiting , chest pain , shortness of breath , fever , or cough . His comorbidities included Parkinson ’ s disease , a history of coronary artery disease , mild chronic kidney disease , and depression . Due to his Parkinson ’ s disease , he required assistance with some activities but was otherwise mobile with the use of a walker . His home medications included carbidopa-levodopa , mirtazapine , clopidogrel , aspirin , metoprolol succinate , and escitalopram . There were no reports of ingestion of caustic substances . Upon presentation , his vital signs were normal with a heart rate of 75 , a blood pressure of 130 / 65 , a respiratory rate of 14 , and a pulse oximetry of 95 % on room
ABSTRACT
Acute esophageal necrosis ( AEN ) is a rare clinical entity found in upper endoscopy . AEN has been seen in patients with severe SARS- CoV-2 infections , with associated hemodynamic instability . We present a case of AEN in the
air . Compulsory nasopharyngeal swab testing upon admission for SAR-CoV-2 was positive . The patient had no known previous diagnosis of SARS-CoV-2 . A physical examination revealed an elderly , well-nourished male in no acute distress . His mucous membranes were moist , his oropharynx was clear , his lungs were clear to auscultation , his heart sounds were normal , and his abdomen was soft with no tenderness and normal bowel sounds . The skin examination was normal and rectal examination revealed brown stool . His relevant laboratory findings included a hemoglobin of 12 g / dL , a platelet count of 167 x103 / uL , a prothrombin time of 10.8 seconds , international normalized ration of 0.94 , a blood urea nitrogen of 34 mg / dL with creatinine of 2.09 mg / dL , glucose of 105 mg / dL , and normal liver enzymes , including an albumin of 3.1 g / dL . The patient had no further episodes of coffee ground emesis and did not have acute melena or rectal bleeding ; however , his repeat hemoglobin trended down to 6.8 g / dL .
An upper endoscopy was performed . The endoscopy revealed normal proximal esophageal mucosa , but at 28cm from the incisors , extending to the lower esophagus , and with an abrupt transition to normal mucosa at the gastroesophageal junction ( Figure 1 ). There was evidence of severe necrosis with mucosa appearing black and violaceous with large ulcerations , consistent with acute esophageal necrosis ( AEN ) ( Figure 2 ). An area of active bleeding in the distal esophagus was identified and was treated with 2 mL of submucosal injection of 1:10,000 ratio of epinephrine , which controlled the bleeding . The stomach and duodenum were normal ( Figure 3 ). Given the classic endoscopic appearance of AEN ,
setting of a mild SARS-CoV-2 infection , with no associated hemodynamic instability . It is possible that the SARS-CoV-2 virus itself , through multiple mechanisms , was the cause of our patient ’ s AEN .
FIGURE 1
Upper endoscopy image of abrupt transition to normal mucosa at the gastroesophageal junction .
FIGURE 2
Upper endoscopy image of the esophagus with black and violaceous mucosa .
FIGURE 3
Upper endoscopy image of normal stomach on retroflexion .
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