Esophageal Ulcers

Common causes of ulceration:

Candida

- Common in HIV/AIDS (immunocompromised) patients

- Described as yellow plaques, patches or exudates or ulcerations on endoscopy.

- Presence of fungal forms with pseudohyphae (represents invasion).

NOTE: Budding yeast often represent an oral contamination and NOT true candidiasis.

- Special stains (PAS/AB & GMS) can be performed if fungi are not seen on H&E and are advised in the following cases:

1. A clinical impression of candidiasis

2. Striking acute inflammation

3. Prominent parakeratosis

4. Clinical history of refractory GERD or EoE

GMS Stain highlighting pseudohyphae

Herpes simplex virus (HSV)

- HSV infects squamous epithelium, thus seen more commonly at the periphery of the ulcer

- Described as "volcano ulcers" on endoscopy

- 3Ms: Margination of chromatin, Molding of nuclear contours, Multinucleation.

- Cowdry A inclusions (intranuclear WITH clear halo).

- Cowdry B inclusions (intranuclear withOUT halo)

HSV is commonly found at the periphery of an ulcer. Careful examination of any ulcer for HSV, CMV or fungal elements is highhly recommended!! Keep in mind that you can have coinfections in the same patient!

The findings can be very subtle. Careful examination is prudent!

- You can perform a HSV immunostain if no classic viral cytopathic effect is seen on H&E. Recommended in any case of esophageal ulceration as the diagnostic features can be easily obscured by the intense background inflammation.

Cytomegalovirus (CMV)

- Endoscopic findings: linear, serpiginous ulcerations in the distal esophagus-Infects endothelial cells, columnar epithelium and stromal cells, thus seen more commonly in the ulcer base

- "Owls eye" nuclear and cytoplasmic viral inclusions with nuclear & cellular enlargements- Background of mononuclear (lymphocytic) inflammation

CMV esophagitis. In this example, the indicated cell (arrowhead) is a markedly enlarged endothelial cell with prominent glassy and smudged cytoplasm. The features are highly suspicious for CMV infection but the nuclear detail is unclear and the characteristic deep magenta inclusion is not seen in this plane. Source: Atlas of Gastrointestinal Pathology. Christina Arnold.

CMV esophagitis. This example of acute esophagitis shows prominent ulceration, mixed inflammation, and reactive endothelial and stromal cells. A CMV immunostain confirmed a diagnosis of CMV esophagitis. Source: Atlas of Gastrointestinal Pathology. Christina Arnold. Esophagus Chapter- Acute Esophagitis.

Can perform CMV immunostain if no classic viral cytopathic effect seen on H&E. Recommended in any case of esophageal ulceration as the diagnostic features can be easily obscured by the intense background inflammation.

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Histology Images: Atlas of Gastrointestinal Pathology. Christina Arnold. Esophagus Chapter- Acute Esophagitis.