Esophageal Lichen Planus: Making The Diagnosis With History And Endoscopy With Histopathologic Evaluation

INTRODUCTION: Esophageal lichen planus (ELP) is a rare manifestation of lichen planus, an inflammatory disease of unknown etiology that commonly affects mucocutaneous membranes. Diagnosing ELP can be challenging because of nonspecific endoscopic or histologic findings, variable symptoms and lack of clear diagnostic criteria. CASE DESCRIPTION/METHODS: A 67-year-old female with a past medical history of gastroesophageal reflux disease and hypertension presented to clinic with two years history of dysphagia to solids, odynophagia, and 30lbs weight loss. Symptoms began with oral ulcers, bleeding gums, and hypogeusia. Her medications included a thiazide diuretic. Physical examination was negative for skin or oropharyngeal lesions and abdominal exam was benign. Laboratory results were negative for antinuclear antibody, anti-Ro/La, and hepatitis C antibody. Patient was started on a proton pump inhibitor and proceeded to esophagogastroduodenoscopy, which revealed an upper esophageal web that was dilated. The mucosa was diffusely inflamed throughout the length of the esophageal body, making the identification of the boundary between squamous and columnar epithelium difficult. A short distal stricture 2 cm above the top of the hiatal hernia was also dilated. Biopsy of proximal esophagus revealed squamous mucosa with basilar lymphocytic infiltrate and scattered apoptotic squamous cells (Civatte bodies) (Figure 1), consistent with a diagnosis of ELP. Distal esophageal biopsy revealed intestinal metaplasia without dysplasia and squamous mucosa with predominantly lymphocytic mixed inflammatory infiltrate and rare apoptotic squamous cells. Patient tolerated endoscopic dilation without complications and patient’s thiazide diuretic was held. Patient re-presented to clinic 6 months after EGD without dysphagia and 9lbs weight gain since previous visit. DISCUSSION: Lichen planus is an inflammatory disease of unknown etiology that commonly affects mucocutaneous membranes but can also involve the esophagus. ELP should be suspected in any patient who has history of lichen planus. Dysphagia and odynophagia are two primary symptoms associated with ELP. A comprehensive endoscopic, radiologic and histopathologic evaluation aid in the diagnosis. ELP is treated with systemic steroids and endoscopic dilation. Endoscopic dilation with discontinuation of potential culprit medications (i.e. thiazides) is a reasonable first step management, as in our case.Figure 1.: Biopsy specimens showing inflammatory infiltration of basal mucosa and scattered apoptotic squamous cells, also known as Civatte bodies (arrow).