LAUSR

DIS 5.4.0 DTD YGAST60823 proof 1 March 2017 11:43 am ce Ga 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Question: A 67-yearold woman with lichen planus involving the skin was referred for evaluation of progressive solid food dysphagia for 10 years. There was a documented 10-lbs weight loss in the last 3months. She described an increase in frequency of meats and breads sticking in the substernal area requiring liquids to facilitate food bolus passage. She had undergone annual upper endoscopies for >10 years that showed erosive esophagitis and esophageal candidiasis. A distal esophageal luminal stenosis was seen on several occasions. She had been treated with balloon dilation for the esophageal stenosis and with 100 101 102 103 104 105 106 107 108 109 110 111 oral fluconazole for esophageal candidiasis on numerous occasions with variable improvement in the dysphagia. Review of outside esophageal biopsies revealed lymphocytic esophagitis with hyperkeratosis and parakeratosis of the squamous epithelium. Physical examination revealed a thin woman without oropharyngeal lesions. There was no cervical or supraclavicular lymphadenopathy. An upper endoscopy showed multiple whitish plaques in the proximal and middle esophagus (Figure A) with biopsies revealing squamous hyperplasia with parakeratosis, lymphocytic inflammation, and necrotic keratinocytes (Figure B), consistent with lichen planus. There was no dysplasia, but Gomori methenamine-silver stain was positive for Candida. The esophageal Candidiasis was treated with oral fluconazole for 2 weeks and the lichen planus with budesonide for 8 weeks. She had initial improvement in dysphagia, but then the dysphagia worsened. She subsequently underwent repeat upper endoscopy 6 months later, which demonstrated multiple white nodules in the middle esophagus (Figure C) and endoscopic mucosal resection (EMR) of several nodules was performed. Histopathology of the EMR is shown in Figure D. What is the diagnosis?