A 26-year-old woman was evaluated due to ongoing odynophagia. Four weeks earlier, she was diagnosed with mandible osteomyelitis caused by indigenous oral bacteria sequel to the infection of a wisdom tooth and was treated with oral levofloxacin and clindamycin after curettage of left mandibular. An upper endoscopy showed a localized ulcerative lesion on the cervical to upper portion of esophagus without signs of erosive reflux esophagitis (Fig. 1). Histopathological investigation of the ulcer revealed signs of inflammation with no signs of malignancy, the presence of cytomegalovirus, granuloma, and eosinophilic infiltration. Following a tentative diagnosis of antimicrobials-induced esophageal ulcer, clindamycin was discontinued, and levofloxacin was replaced with moxifloxacin. Her symptom recovered four weeks later, and an upper endoscopy performed eight weeks did not show any lesion (Fig. 2).
Fig. 1.
Antimicrobials-induced esophageal ulcer before treatment.
An upper endoscopy showed a localized ulcerative lesion on the cervical esophagus without signs of erosive reflux esophagitis as well as normal appearance of the stomach and duodenum (Fig. 1).
Fig. 2.
Antimicrobials-induced esophageal ulcer after treatment.
After discontinued of clindamycin and levofloxacin, the patient remains asymptomatic spontaneously without antacids, and an upper endoscopy performed eight weeks did not show any lesion (Fig. 2).
The reason for esophageal ulcer could be due to antimicrobials-induced esophageal ulcers. Of the antimicrobials-induced esophageal ulcers, doxycycline was most frequently reported, and rarely by tetracycline, ciprofloxacin, rifampin, and clindamycin [1]. Although there were previous reports of clindamycin-induced esophageal ulcer as a rare complication [[1], [2], [3]], we could not find any published reports of esophageal ulcer by levofloxacin. For these reasons, we consider that clindamycin is the most likely cause of the esophageal ulcer in our case. Its suggested mechanisms for development of esophagitis by clindamycin include delayed passage of drugs and prolonged mucosal contact at physiological constriction points, which leads esophageal irritation and ulceration [4]. Symptomatic treatment with proton pump inhibitor is usually performed, however, their efficacy has not been verified. As it is usually self-limiting, discontinuation of the suspected agent is effective [[1], [2], [3]]. To tackle antimicrobial resistance, antimicrobial stewardship including knowledge of adverse effect of antimicrobials is needed. Clinicians should be aware of antimicrobials-induced esophageal ulcer as a rare adverse effect of antimicrobials.
Funding
This work was supported by the NCGM Intramural Research Fund [grant number 20A05].
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Ethical approval
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
CRediT authorship contribution statement
Satoshi Ide: Conceptualization, Data curation, Formal analysis. Masahiro Ishikane: Conceptualization, Data curation, Formal analysis. Norio Ohmagari: Supervision.
Declaration of Competing Interest
The authors report no declarations of interest.
Acknowledgment
We thank all the clinical staff at the National Center for Global Health and Medicine for their dedicated clinical practice and patient care.
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