You may have received pathology reports with a diagnosis of “lymphocytic
esophagitis pattern of injury” and asked youself two perfectly reasonable
questions: 1. “Well, what does that mean?” 2. “Is it
even a real disease?” The answer to the first question is that no
one knows exactly what it means with regard to its clinical significance.
The answer to the second question is that
lymphocytic esophagitis (LE) is currently best described as a histologic pattern of injury, the underlying
etiology of which remains uncertain. Although this finding is relatively
rare, it is reported with sufficient frequency at
Inform Diagnostics to warrant the presentation of a brief review of the subject to our clinicians.
LE was first described by Rubio et al in 2006. 1 The histologic features
laid out in that paper continue to accurately define this pattern of injury:
a dense, patchy lymphocytic infiltrate in the esophageal squamous epithelium
that is most pronounced in the peripapillary areas (see image from the
“Under the Microscope Section” above). There is also accompanying
intercellular edema, or spongiosis, in the affected areas, as well as
an absence of significant eosinophilic or neutrophilic inflammation. The
original study by Rubio and a more recent report 2 suggest that LE may
be a manifestation of Crohn’s disease, but it is important to note
that the evidence only supports this association with any strength in
pediatric patients. Another study by Purdy et al 3 could not demonstrate
a significant correlation with any other disease state. Nonetheless, gastriointestinal
pathologists continue to observe this pattern, and the lack of unequivocal
clinical correlates in the literature to help define LE prompted Dr. Salima
Haque and Dr. Robert Genta of Inform Diagnostics to review a large number
of cases from the formidable Inform Diagnostics database. 4
The most interesting finding in this recent Inform Diagnostics study is that lymphocytic
esophagitis may mimic eosinophilic esophagitis (EE), both clinically and
endoscopically. About one third of the patients in the study presented
with dysphagia or odynophagia, eliciting a clinical suspicion of EE. Less
commonly, significant reflux was the presenting symptom. One-third of
patients had endoscopic findings that included rings, white plaques, and
strictures, but furrows seemed to be less common than in eosinophilic
esophagitis. One less common clinical finding was that of a motility disorder.
A small proportion of patients were found to have esophagitis (usually
LA grade A), while many had an endoscopically normal esophagus. Demographically,
most patients with a histologic diagnosis of LE were women in their 7th
decade (median age 63 years; 60% female). The vast majority of patients
with LE had a medication history that included PPI use, but as the study
is retrospective, no conclusions regarding causality can be made. Although
no significant associations with other diseases were identified, the finding
that lymphocytic esophagitis can be a mimic of eosinophilic esophagitis
In conclusion, both the etiology and clinical significance of lymphocytic
esophagitis remain elusive. Although it has been linked with Crohn’s
disease in children, no firm correlates with other diseases have been
established in adult patients. The recent study by Drs. Haque and Genta
should raise awareness of LE, especially regarding its potential to mimic
eosinophilic esophagitis clinically and endoscopically. Continued collaboration
between clinicians and pathologists will be needed to arrive at a more
complete understanding of LE, which, as Haque and Genta point out in their
new study, is “a condition in search of a disease.”5
1. Rubio CA, Sjodahl K, Lagergren J. Lymphocytic esophagitis: a histologic
subset of chronic esophagitis. Am J Clin Pathol 2006;125:432-437.
2. Ebach DR, Vanderheyden AD, Ellison JM, Jensen CS. Lymphocytic esophagitis:
a possible manifestation of pediatric upper gastrointestinal Crohn’s
disease. Inflamm Bowel Dis 2011;17:45-49.
3. Purdy JK, Appelman HD, Golembeski CP, McKenna BJ. Lymphocytic esophagitis:
a chronic or recurring pattern of esophagitis resembling allergic contact
dermatitis. Am J Clin Pathol 2008;130:508-513.
4. Haque S and Genta RM. Lymphocytic Esophagitis: a Clinicopathologic study.
Gut, (in press); 2011.
5. Loch J. Pirandello: Six Characters in Search of an Author. Cambridge,
UK: Cambridge University Press, 2005.