Immune Checkpoint Inhibitor-Induced Lymphocytic Esophagitis

Abstract

Immune checkpoint inhibitors (ICIs) have emerged as effective treatments for a wide variety of advanced malignancies. However, their use is associated with numerous immune-related toxicities, including within the gastrointestinal tract. We present a rare case of checkpoint inhibitor-induced lymphocytic esophagitis. A 79-year-old male with a past medical history significant for metastatic renal clear cell carcinoma on nivolumab presented to the hospital with dysphagia and symptomatic choledocholithiasis. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) for the extraction of stones and esophagogastroduodenoscopy (EGD) for dysphagia, which showed esophagitis. Biopsies revealed lymphocytic infiltration of the epithelium, dyskeratotic keratinocytes, and acanthosis, raising suspicion for nivolumab-associated lymphocytic esophagitis. Treatment includes proton pump inhibitors and steroids; however, efficacy is not well described due to the rarity of the condition.

Keywords: esophagitis; ici esophagitis; immune check-point inhibitor; lymphocytic esophagitis; nivolumab.

Figure 1. Endoscopy and pathology of ICI-induced esophagitis

1A. Endoscopy image showing an inflamed lower third of the esophagus with erythema and subtle furrows. 1B. Esophageal biopsy specimen demonstrating features of lymphocytic esophagitis. Inflamed squamous epithelium with an infiltrate of lymphocytes that appear as “squiggle cells” because of their stretched-out appearance (green arrows) and associated dyskeratotic keratinocytes (blue arrows). The red arrows indicate the basal keratinocytes.