Case summary
(a) Clinical situation
A 67 years old female presented to our outpatient clinic for evaluation
of microcytic anemia that was incidentally picked up on routine chronic
disease follow-up. Her past medical history include hypertension, type 2
diabetes mellitus, hypothyroidism and osteoporosis. She was
asymptomatic; in particular she did not have any dysphagia, odynophagia
or reflux symptoms. She was started on oral alendronate 70mg once a week
a year ago when she was diagnosed with osteoporosis after a compression
fracture. Her other medications included telmisartan 80mg OM, iron
polymaltose 100mg OM, cholecalciferol capsule 2000u OM and amlodipine
7.mg OM.
(b) Course of events
She was initially only keen for non-invasive tests hence a barium meal
was performed, which showed a diffuse “cobblestone” appearance but no
stricture or significant gastro-esophageal reflux. She subsequently
agreed for oesophago-gastro-duodenoscopy (OGD), which showed diffused
white nodular lesions along esophagus starting from oropharynx with
cobblestone appearance, but no ulcer or mass noted. (Fig. 1) Segmental
esophageal biopsies were negative for fungal stain and did not show any
pathology. In the absence of infection, eosinophilic esophagitis and
dysplasia, her “Cobblestone” esophagus was attributed to bisphosphate
use, hence alendronate acid was held off.
(c) Clinical resolution
She underwent serial barium meal over the next 1 year with significant
interval improvement. (Fig. 2)