Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019 RARE CAUSES OF ACUTE ESOPHAGITIS WITH SEVERE DYSPHAGIA IN CHILDREN Smaranda Diaconescu1,2, Cristina-Gabriela Șchiopu1, Nicoleta Gimiga1,2, Stefana Maria Moisa2, Gabriela Ghiga2, Lorenza Donea*1, Gabriela Ștefănescu2,3, Oana-Maria Roșu 3,4 1 Department of Pediatric Gastroenterology - “Sf. Maria” Clinical Emergency Children’s Hospital, Iași, Romania 2 University of Medicine and Pharmacy “Gr. T. Popa”, Iași, Romania 3 Department of Clinical Gastroenterology, “Sf. Spiridon” Hospital, Iași, Romania 4 Ph. D. student, University of Medicine, Pharmacy, Sciences and Technology, Târgu Mureș, Romania Corresponding author: Lorenza Donea, e-mail – [email protected] ABSTRACT Esophagitis in pediatrics could have various causes, such as acid and non-acid gastroesophageal reflux, food allergies, infections, trauma, and iatrogenic causes. A three year old patient was admitted into the General Pediatrics department in our hospital for abdominal pain, vomiting, dysphagia, mild diarrhea, loss of appetite, fever (39°C) , with the onset of the symptomatology occurring 4-5 days prior to hospital admission. Clinical exam reveals dysphagia for liquids and solids and diffuse abdominal pain. Upper gastrointestinal endoscopy reveals an esophagus with multiple ulcerations and aphthoid-type lesions, as well as a friable mucosa that bleeds easily in contact with the endoscope. Candida albicans was found in feces. Considering the negative anamnesis for ingestion of corrosive substances, the case raises the suspicion of lesions associated with Candida albicans or of a viral etiology. The treatment with proton pump inhibitors, antimycotics, and preparations with antiviral and immunomodulatory actions determined a rapid favorable evolution. The inflammatory lesions of the esophagus can be varied, often having non-specific aspect. The endoscopic modifications of the mucosa are extremely typical in some cases. Careful differential diagnosis is mandatory, as in the long term all types of untreated esophagitis can become complicated by the development of esophageal stenoses. Key words: dysphagia, esophagitis, child INTRODUCTION MATERIAL AND METHODS Esophagitis can have various causes, Three year old patient with personal such as acid and non-acid gastroesophageal pathological history of surgically corrected reflux, food allergies, dysmotility resulting bilateral inguinal hernia and pharyngitis from various causes, different infections treated recently with antibiotics and iatrogenic causes. (clarithromycin, ceftriaxone) is admitted Dysphagia is one of the first clinical into the General Pediatrics department in signs that should get the pediatrician’s our hospital for abdominal pain, vomiting, attention, particularly when it has a sudden dysphagia, mild diarrhea, loss of appetite, onset. fever (39°C), with the onset of the Endoscopic exploration is essential for symptomatology occurring 4-5 days prior to determining the etiology and the optimal hospital admission. therapeutic approach. The family inquiry revealed the following: 35 years old mother with a 49 Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019 history of two abortions; 37 years old to intestinal gas, does not appear to have father; 6 years old brother, apparently pyelocalyceal distension, no direct images healthy; 10 years old brother with stage five of calculi, spleen size within normal limits kidney failure and peritoneal dialysis; one (77mm), homogenous structure, accessory brother dead at 4 months of age with spleen to the lower pole with a 13 mm congenital heart disease – the mother diameter, semi-full urinary bladder, with cannot specify the diagnosis; maternal echogenic floating sediment, 7 mm thick grandfather with liver cirrhosis. inter-rectovesical free fluid, multiple lymph Clinical state upon admission: nodes at the root of the mesentery. A slightly altered general state, afebrile, pale decision is made to transfer the patient into elastic skin, mucosa with normal the Pediatric Gastroenterology department pigmentation, lateral-cervical micro- to perform an upper gastrointestinal polyadenopathy, cardiovascular system endoscopy. (AV=100 b/min), dysphagia following solid The upper gastrointestinal foods, soft non-tender abdomen, diffuse endoscopy reveals ulcerations and aphthoid abdominal pain occurring spontaneously lesions throughout the esophageal tract with and on palpation, physiological bowel mild bleeding upon contact with the movements and micturition, no signs of endoscope, and competent cardia; diffuse meningeal contracture. Laboratory mucosa congestion is seen in the stomach. examinations revealed lymphocytosis, (Fig. 1) The bulbus and the second part of moderate hepatic cytolysis syndrome, the duodenum appear normal upon hyposideremia, and hypocalcemia. endoscopy. Considering the aspect of the Coprocytogram revealed Candida albicans mucosa and the negative history for yeasts. ingestion of corrosive substances, the During hospital admission the described lesions could be associated with abdominal pain persists and particularly Candida albicans (which is otherwise intensifies both after ingestion of semi-solid present in feces) or could have a viral pureed foods and after ingestion of liquids. etiology. Abdominal ultrasound: normal size liver, Treatment was initiated with proton homogenous structure, normal reflectivity, pump inhibitors, antimycotics and folded gallbladder with no calculi, the main preparations with antiviral and bile duct and the intrahepatic bile ducts are immunomodulatory actions, intravenous not dilated, normal size pancreas, fluids and semi-solid food intake with room homogenous structure, right kidney with no temperature foods and a rapid favorable pyelocalyceal distension, no direct images evolution subsequently. of calculi, left kidney partially visible due 50 Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019 Figure 1. Endoscopic images of the esophagus RESULTS AND DISCUSSIONS difference between the values of 25(OH)- Reflux esophagitis is frequently D3 in children and teenagers with encountered in children. The primary eosinophilic esophagitis and/or causes of reflux in the pediatric population gastroesophageal reflux disease and those can include neurological or metabolic in normal subjects. (7, 8) While the Savary disorders, hormonal imbalances and the classification was largely used in the past behavior of the mother during pregnancy years, nowadays the Los Angeles (obesity and high-fat diets, caffeine, sweets, classification is widely used (Table 1). (9) alcohol consumption, and smoking). In adults, the combination of calcium and Grade A One or more lesions no longer warfarin channel blockers is an independent than 5 mm, located in the folds risk factor for gastroesophageal reflux disease (GERD). Recent evidence indicate Grade B One or more lesions > 5mm, that GERD induces the onset and located in the folds, but that do perpetuation of atrial fibrillation. (1, 2, 3, 4) not extend from one fold to The specific digestive signs can include: another effortless vomiting, regurgitations, sometimes hematemesis, hiccups that last Grade C Continuous lesions between for a long period of time, deglutition folds, but lower than 75% of disorders, pyrosis in older children, the circumference odynophagia. (5, 6) Neurobehavioral Grade D Circumferential lesions modifications include irritability, inconsolable crying, arching of the back or cervical muscle contracture that can imitate Table 1. Los Angeles classification of torticollis. Respiratory signs comprise Gastroesophageal Reflux Disease nighttime coughs, frequent respiratory tract Corrosive esophagitis is primarily due to infections, and recurrent wheezing. Other the accidental ingestion of corrosive signs are also described for reflux disease, substances (potassium hydroxide, ammonia, such as dental erosion, recurrent laryngitis, sulfuric acid, oxalic acid). Upper recurrent middle ear (otitis media) gastrointestinal endoscopy should be infection, etc. For the pediatric population, performed within maximum 24-48 hours to however, studies do not prove a significant determine the severity and extent of 51 Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019 mucosal lesions, as these constitute gastroesophageal reflux disease, reflux predictive factors for the risk of perforation, esophagitis or hiatal hernia) or torticollis as well as for the evolution towards late can be taken into consideration as complications such as stenoses. (10) differential diagnosis for certain nursing The physiopathological mechanism infants. Complete blood count do not reveal of eosinophilic esophagitis is not very specific modifications that could allow for clearly understood, although it is thought the differential diagnosis of the various that food allergens could be the primary forms of esophagitis. Anemia (iron- triggering factors for this disease (eggs, deficient or post-hemorrhagic) can be cow’s milk, peanuts, fish, seafood, corn, present, and so can non-specific soy, chicken meat or beef), while a personal leukocytosis. High levels of eosinophils can or familial history of atopy (asthma, be detected in patients with eosinophilic eczema, chronic rhinitis, etc.) constitutes a esophagitis, requiring the correlation with favoring factor. Endoscopy can identify the clinical context (atopic patient with no multiple aspects, ranging from normal to response or weak response to PPI furrowed