At the focal point| Volume 77, ISSUE 1, P131-132, January 2013

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Esophageal hyperkeratosis after proton pump inhibitor therapy in a patient with esophageal eosinophilia

      A 57-year-old man who had experienced heartburn and dysphagia for 4 months was referred for endoscopy. The results of his physical examination were normal, without ocular, cutaneous, or atopic findings. Endoscopy showed linear furrows and whitish exudates in the distal esophagus (A) . Esophageal eosinophilic infiltration was confirmed in both the distal (45 eosinophils per high-power field) and proximal (25 eosinophils per high-power field) esophagus (A, inset). Consensus recommendations were made, and the patient was treated with rabeprazole 20 mg twice daily for 8 weeks and achieved clinical remission. On follow-up endoscopy and biopsy, the endoscopic features and esophageal eosinophilia were in remission. Interestingly, the distal esophagus was involved by several longitudinal white plaque lesions (B), which had a characteristic fish-scale pattern (C). Histologic examination revealed a prominent granular layer and severe hyperkeratosis over the squamous epithelium, mimicking the corneal layer of epidermis (D), without dysplasia. Esophageal fungus, viral infections, and nutritional deficiencies were ruled out. Three months later, the patient remained asymptomatic while receiving proton pump inhibitor therapy, and the findings persisted on repeat endoscopy.
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