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Gram-Negative Bacteremia

Rare Sequelae of Black Esophagus


Forman, Robin, DO; Huysman, AnnMarie, M.D.; Cohen, Seth, M.D.

American Journal of Gastroenterology: September 2005 - Volume 100 - Issue - p S51–S52
Supplement Abstracts Submitted for the 70th Annual Scientific Meeting of the American College of Gastroenterology: ESOPHAGUS

Division of Digestive Diseases, Beth Israel Medical Center, New York, NY and Internal Medicine, Mount Sinai Medical Center, New York, NY.

Purpose: A 43 year-old woman presented with hypertension, chest pain, and shortness of breath.

Her past medical history included hypertension, diabetes mellitus, coronary artery disease, myocardial infarction (MI), cerebrovascular accident, chronic renal insufficiency, and antiphospholipid antibody syndrome.

The patient was admitted to the CCU for hypertensive emergency. On hospital day #2 she had an episode of hemetemesis with epigastric pain and dysphagia. She was hemodynamically stable and afebrile. Physical exam revealed mid-epigastric tenderness and brown guaiac positive stool. White count was 15.2 k/mm3, hemoglobin was 11.1 g/dL, creatnine was 1.8 mg/dL, platelets and coagulation studies were normal. Esophagogastroduodenoscopy (EGD) revealed markedly abnormal mucosa, covered with confluent black exudates with a “burnt marshmallow appearance” in the distal third of the esophagus. Biopsies showed pseudomembranes with polymorphonuclear cells (PMNs) and squamous epithelium with numerous clusters of PMNs, consistent with acute necrotizing esophagitis.

Oral sucralfate and bid pantoprazole were initiated. On hospital day #5, the patient was discharged. One week following the initial EGD she was complaining of continued dysphagia and odynophagia. EGD at that time revealed marked improvement of the mucosa, but still showed severe erythema with overlying yellowish exudate. Repeat biopsies showed histological improvement of acute inflammation by resolution of PMNs. However, the presence of gram negative bacilli was noted. Silver stains of the tissue revealed yeast and pseudohyphae depicting superinfection with candida species.

Three days following the second EGD, the patient was admitted to the hospital for fever and gram (-) bacteremia, Proteus species. This correlated with the GNR seen on the biopsy from the second endoscopy. The patient was treated with oral ciprofloxacin and discharged.

Black esophagus is a rare endoscopic finding. Although the pathogenesis remains unknown, an ischemic origin appears likely. It seems to occur in patients with overall poor general health and treatment consists of conservative therapy. The natural history of the disease is that of spontaneous resolution. Our patient was admitted a few days after her second EGD for gram (-) bacteremia, an unreported sequelae of acute necrotizing esophagitis. We postulate that the bacteremia was a result of the manipulation of the mucosa from endoscopy and biopsy.

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