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Dysphagia Caused by Esophageal Actinomycosis

Published:January 24, 2015DOI:https://doi.org/10.1016/j.cgh.2015.01.012
      A 71-year-old woman presented with worsening odynophagia and weight loss requiring hospitalization while on treatment with decitabine for newly diagnosed acute myeloid leukemia. Empiric treatment with a proton pump inhibitor and an antifungal agent did not alleviate the symptoms. Physical examination was unremarkable except for pallor and mild tachycardia, with a heart rate of 108 beats per minute. Laboratory findings included pancytopenia, with a white blood cell count of 280/uL, a hemoglobin level of 6.9 g/dL, a platelet count of 13,000/uL, and a normal electrolyte level. She received 2 U of packed red blood cells and 3 U of a platelet transfusion, after which she underwent an upper endoscopy. It showed extensive and deep ulceration involving 80% circumference at 32 to 35 cm from the incisors (Figure A). A pathology examination showed inflamed granulation tissue with abundant bacterial colonization. The bacteria were gram-positive rods, less than 1 μm in width, with focally branching filaments (Figures B and C). The differential diagnosis for these bacteria included Actinomycetes, nocardia, and dermatophilus. Culture confirmed that the bacteria were Actinomycetes. The patient was started on amoxicillin 500 mg 3 times a day. She was switched to erythromycin because she developed a rash. She continued the erythromycin for 2 months and then stopped after a remarkable improvement of her symptoms. A follow-up endoscopy showed complete healing of the ulcer with a mild fibrotic stricture treated by balloon dilation.
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