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)