© Georg Thieme Verlag KG Stuttgart · New York
Diffuse esophageal parakeratosis
18. April 2007 (online)
A 31-year-old woman, who suffered from chronic alcohol abuse, presented with hematemesis and loss of consciousness 2 hours after ingesting toilet bowl cleaner and sedative pills. Over the previous 6 months she had suffered worsening depressive symptoms, with increased alcohol intake, inadequate diet, and a rapid weight loss of 20 kg. An urgent endoscopy revealed extensive gastric and duodenal hemorrhage as a result of caustic injury. The esophagus was not a source of bleeding; however, it showed an unusual appearance of thick mucosa with orderly displayed rings and furrows (Figure  a). The furrows were particularly prominent when the lumen constricted upon irrigation (Figure  b). The lesion started with discrete patches at the upper esophagus (Figure  c), extended diffusely through the entire esophagus, and ended up at the esophagogastric junction. A section of square-shaped mucosa at the upper esophagus was peeled off by random grasping using biopsy forceps (Figure  d). Epithelial parakeratosis was demonstrated by microscopic examination (Figure ). The patient was treated with alcohol abstinence, proton-pump inhibitor, standard tube-feeding diet, and supplements of thiamine, pyridoxine, and cyanocobalamine. A follow-up endoscopy 40 days later revealed normal esophageal mucosa except for scattered candidal infections.
Figure 1 Endoscopic finding of diffuse esophageal mucosal thickening. a Thick mucosa with orderly displayed rings and furrows. b Prominent furrows during lumen constriction. c The upper esophagus showing discrete lesion patches. d Random grasping with biopsy forceps removed a square-shaped section of mucosa at the upper esophagus.
Figure 2 Biopsy of upper esophagus reveals a dense layer of parakeratosis covering the normal-appearing squamous epithelium (hematoxylin and eosin, original magnification × 100).
Diffuse esophageal hyper-/parakeratosis is an uncommon endoscopic finding. It is associated with conditions like tylosis, mucosal hyperkeratosis syndrome, and pachyonychia congenita . In addition to genetic diseases, it may be linked to ethanol exposure, duodenal reflux, riboflavin deficiency, and zinc deficiency    . Rapid and complete recovery after nutritional supplement in this patient suggests a causal-result relationship between them.
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J. T. Lin, MD
Department of Internal Medicine
National Taiwan University Hospital
7 Chung-Shan South Road