A Rare Case of Methotrexate Precipitating Esophageal Dissecans Superficialis

Introduction: Esophageal Dissecans Superficialis (EDS) is a rare endoscopic finding characterized by mucosal sloughing into the esophageal lumen. While harboring no malignant potential, its etiology is yet to be elucidated. Case Description/Methods: An 82-year-old White man with past medical history of GERD, psoriatic arthritis, tobacco use disorder ( >35 years), and bladder cancer treated with chemotherapy in 2021 presented for esophageal dysphagia to solids that started 1 year after completing chemotherapy. He also had food regurgitation poorly controlled with pantoprazole 40 mg daily. His psoriatic arthritis was treated with meloxicam 15 mg daily for over 20 years and methotrexate 20 mg weekly for the past 5 years. Barium esophagram showed distal esophageal stricture 9 cm in length restricting passage of a 13 mm barium tablet. Initial EGD showed severe sloughing of whitish esophageal mucosa with luminal narrowing between 30 cm and 40 cm from the incisors (Figure 1). Six subsequent EGD’s demonstrated mucosal sloughing, luminal narrowing, and biopsy-proven acute inflammation with ulcerative changes from the mid to distal esophagus. Immunofluorescence staining was negative. TTS balloon dilation was performed on a 2 cm focal stricture in the distal esophagus from 12mm to 15mm. A diagnosis of EDS was confirmed endoscopically, likely from methotrexate with possible contribution from meloxicam and active smoking. A medication review determined prior chemotherapy was an unlikely factor as mucosal injury peaks in 14 days and resolves after discontinuation. Methotrexate-induced injury can persist for months. A repeat EGD is scheduled to evaluate the esophageal lumen after methotrexate and meloxicam cessation. Discussion: Despite its dramatic presentation, EDS is a benign condition that generally resolves without long term damage to the esophagus. It has been linked to medications (NSAID’s/methotrexate), autoimmune disorders, heavy smoking, and physical trauma, although most cases are idiopathic. This case would represent only the third case in literature of methotrexate-induced EDS, though it is likely the patient’s chronic meloxicam and heavy smoking played roles. When symptomatic, EDS is associated with dysphagia, odynophagia, heartburn, abdominal pain, and nausea. Resolution has been reported with stopping potential causative medications and use of acid-suppressing medications. This case highlights the importance of recognizing this rare endoscopic finding and being aware of its wide array of possible insults.Figure 1.: EGD showing esophageal dissecans superficialis.