A 73-year-old woman with acute myeloid leukemia presented 4 months after allogeneic stem cell transplant with abdominal pain, solidfood dysphagia, and odynophagia. Initial upper endoscopy without biopsies was normal. Repeat upper endoscopy performed 4 months later for ongoing symptoms revealed esophagitis dissecans superficialis (EDS) (Figure 1). Biopsies of the esophagus (Figure 1), nodular antral mucosa, and normal-appearing duodenal mucosa were suggestive of graft-vs-host disease (GVHD). On upper endoscopy, GVHD may present with ulcers, erosions, nodularity, subepithelial hemorrhage, or normal-appearing mucosa, but there are few reports of GVHD presenting with EDS. 1,2 EDS is a rare endoscopic finding characterized by sloughing of large areas of the superficial esophageal mucosa. Presentation is variable but includes dysphagia, abdominal pain, anemia, weight loss, and vomiting of casts of the esophageal mucosa. 3,4 Known risk factors include medications (e.g., nonsteroidal anti-inflammatory drugs and bisphosphonates), smoking, cutaneous disorders, and trauma. 1,5 This case highlights that in patients at risk for GVHD presenting with upper gastrointestinal symptoms, mucosal biopsies should be obtained even if the examination seems endoscopically normal. Sixteen months after initial diagnosis, the patient has been treated with ruxolitinib (discontinued because of thrombocytopenia), prednisone, and tacrolimus. This has induced improvement in symptoms and some endoscopic and histologic improvement.
