Esophageal ulcer associated with inappropriately taken doxycycline: A benign mimicker of esophageal cancer

A 16yearold girl visited our clinic because of chest pain that was exacerbated with swallowing. Ten days previously, the patient had spilled boiling water on herself and burned her legs. She saw a dermatologist, who prescribed doxycycline (100 mg per day in tablet form) to prevent skin infection. Five days previously, the patient took a doxycycline tablet with a small amount of water just before going to bed. She fell asleep in the supine position soon after taking the tablet. The following morning, she noticed chest pain and a dry cough. She visited our clinic complaining of difficulty swallowing because it exacerbated the associated chest pain. Physical examination, chest Xray, and electrocardiograph results were unremarkable. Endoscopy of the upper gastrointestinal tract revealed a geographic ulcer that encompassed the entire circumference of the esophagus around the bronchoaortic constriction (Figure 1), which is often interpreted as suggesting esophageal cancer. However, because she had taken doxycycline the day before onset, the patient was diagnosed with doxycyclineinduced esophageal ulcer and treated with intravenous fluid alimentation, a proton pump inhibitor, and analgesics. Her symptoms subsided within 1 week. All examinations to exclude other disorders revealed no remarkable findings, as follows: biopsy specimen of the ulcer indicated pathologically inflammatory granulation without malignancy; serum antinuclear antibodies, antidesmoglein antibodies, antiherpes simplex virus antibodies, and anticytomegalovirus antibody were all negative. Followup endoscopies performed 2 weeks and 6 months thereafter confirmed improvement. Approximately 100 types of medication are reported to cause esophageal injuries.1 Druginduced esophageal injuries are classified by their etiology as follows: (i) injury resulting from acidic antibiotics, (ii) chemical esophagitis caused by bisphosphonates such as alendronate, (iii) hyperosmotic injury caused by potassium chloride or quinidine, and (iv) distal esophagitis associated with nonsteroidal antiinflammatory drugs in patients with gastroesophageal reflux disease.2 Older people are prone to develop druginduced esophageal injury because of decreased esophageal motility and saliva production, cardiac enlargement, and polypharmacy.1,2 Antibioticrelated esophageal injury, however, frequently occurs in young women without underlying disorders. Doxycycline most commonly causes antibioticrelated esophageal injury, and this causative medication and its indication can explain the occurrence of antibioticrelated esophageal injury in young women. When administered orally, doxycycline causes chemical injury to adjacent tissues because of acidic conditions generated by the dissolution F IGURE 1 Endoscopy of the upper gastrointestinal tract revealed a geographic ulcer that encompassed the entire circumference of the esophagus around the bronchoaortic constriction, which can be misdiagnosed as the finding of esophageal cancer