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Gastric emphysema (GE) in association with hepatic portal vein gas (HPVG) is a rare, benign medical condition that is very seldom caused by noninvasive positive pressure ventilation (NIPPV). This report describes a patient who developed GE along with gastric vein gas and HPVG, most likely due to multiple episodes of vomiting in combination of using bilevel positive airway pressure (BiPAP), a form of NIPPV. The patient responded to conservative treatment with intravenous fluids, pantoprazole, and the urgent cessation of BiPAP and oral intake.

INTRODUCTION: All that looks like cancer is not always cancer. Esophageal Actinomycosis is a fine example that frequently mimics malignancy. Actinomyces is a bacteria acting like fungi which extremely rarely infects the esophagus in immunocompetent hosts. Risk factors are unknown due to paucity of data. CASE DESCRIPTION/METHODS: A 79-year-old African American woman was admitted with mild hematemesis. She had progressive, painless dysphagia for solids for 6 weeks and had lost 12 lb. She had curative lobectomy for lung cancer and quit smoking 10 years ago. She had COPD and GERD. Medications included Budesonide-Formoterol and Albuterol inhalers. She had no history of chemo/radiotherapy, tuberculosis, HIV, or diabetes. Physical exam was normal. CBC, renal function and LFTs were normal. CT chest with contrast showed air-fluid levels within the esophagus and wall thickening. EGD revealed a 1 cm friable mass in distal esophagus. Biopsy confirmed actinomycosis and candida esophagitis. She was discharged on Ceftriaxone 2 g/day for 4 weeks and oral Fluconazole 200 mg/day for 3 weeks. At 1-month follow up, dysphagia had improved and she was switched to oral Amoxicillin for 6 months. DISCUSSION: Actinomyces is an anaerobic, gram-positive, filamentous, branching rod. It grows as normal flora in the mouth and GI tract. Esophageal Actinomycosis is exceedingly rare in immunocompetent people with only 28 cases indexed in PubMed in English. 13 cases were reported in the US. 2/3 of patients were immunocompromised. It invades the esophagus following mucosal breach, and presents as a mass, esophagitis, ulcer, abscess, fistula, or stricture causing dysphagia/odynophagia. It is a great imitator, often misleading physicians, thereby triggering malignancy work-up. Diagnosis involves imaging and biopsy. Microscopy reveals yellow sulfur granules in 50% of cases. Actinomyces is difficult to isolate with culture yield as low as 24%. RNA sequencing can provide a quick, accurate diagnosis in future. Patient education and counseling is the cornerstone of successful prolonged antibiotic therapy. An initial course of IV penicillin G or Ceftriaxone for 4-6 weeks is followed by oral penicillin V or amoxicillin for 6-12 months. Necrotic ulcer, fistula, or abscess is managed surgically. We believe that inhaled corticosteroids may have created the milieu for the growth of Actinomyces and Candida in the esophagus by impairing local defenses. 43% of inhaled corticosteroid is deposited in the esophagus according to Gamma scintigraphic studies.

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