A, - Pseudoxanthoma Elasticum 11 cases- Annals of Dermatology Lowell A Goldsmith - Fitzpatricks Dermatology in General

and Venereology 2003;130:318-320. Medicine 6th edition.

6. DA Burns; SM Breathnach; Neilcox; Christopher. E. Griffith - Rooks 8. Haaga, Lanzieri, Gilkeson - CT and MR imaging of the whole body
Textbook of Dermatology -7th edition. 4th edition.
7. Irwin M Freedberg, Arthur Z Eisen, Klauss Wolff, K Frank Austen,

Doxycycline Induced Acute Erosive Oesophagitis

and Presenting as Acute Dysphagia
VG Shelat*, M Seah*, KH Lim**
Abstract
Introduction: Drug induced oesophageal disease is common. Doxycycline is one of the commonest cause of drug
induced oesophageal ulcers. The medical community often under recognizes the importance of drug induced
oesophageal lesions and fails to deliver proper advice and instructions related to drug ingestion. The diagnosis
is usually clinical although endoscopy is the gold standard diagnostic tool. Treatment is symptomatic with
discontinuation of the drug often being sufficient. Long-term sequelae are infrequent and acute complications
uncommon.
Clinical picture: A 22-year-old college student was prescribed doxycycline capsules for acne and developed
dysphagia. Upper gastrointestinal endoscopy revealed acute erosive oesophagitis.
Treatment and outcome: She was managed symptomatically with proton pump inhibitors and her dysphagia
improved over a period of three days. She was discharged with proper advice regarding medication ingestion
and proton pump inhibitor for four weeks.
Conclusion: Drug induced oesophageal disease is a preventable self-limiting condition. Proper advice regarding
medication ingestion is essential for prevention.

Introduction
D rug induced oesophageal disease (DIOD) was first reported
in 1970.1 More than 100 drugs have been implicated in the
causation of oesophageal disease and more than 1000 cases of
drug induced oesophageal injury have been reported. 2 Common
medicines include tetracycline, doxycycline, minocycline,
acetylsalicylic acid, potassium chloride, ferrous sulphate,
quinidine, alprenolol, alendronic acid, vitamin C, penicillins,
clindamycin and non-steroidal anti-inflammatory drugs.
Chemical content, drug formulation and patient factors are
specific for the drug induced oesophageal lesions. The possibility
of drug induced oesophageal damage should be suspected
in a patient who complains of dysphagia, odynophagia and
retrosternal chest pain. The oesophageal injury ranges from mild
inflammation to acute ulceration, haemorrhage, perforation or
oesophageal stricture.
Gastrointestinal endoscopy will confirm the diagnosis in
appropriate cases and also helps to rule out sinister oesophageal
disease. It is not necessary in the acute setting if the history is
specific and discontinuation of the offending drug has already
started to relieve the symptoms. Acid reduction is commonly
advised, but its role is not evidence based. Giving appropriate
instructions to the patient can many times prevent such
oesophageal injuries. We report a doxycycline induced acute
ulcerative oesophagitis in a young healthy college student
without prior history of oesophageal disease.
Case Report
A 22-year-old female college student went to a local polyclinic
Registrar, **Consultant, Division of Upper Gastrointestinal Surgery,
*
to seek advice for acne. The acne distribution was facial and
had not responded to topical over the counter preparations. She
was prescribed doxycycline capsules for six weeks. She did not
have any past history of oesophageal disease. There was also
no history of smoking or alcohol intake. She did not have any
known drug allergies and was fit and healthy. After two days
of doxycycline ingestion, she developed retrosternal chest pain
and odynophagia. She stopped consuming the drug after three
days. The odynophagia continued and on the fourth day she
presented to the emergency department.
She had no history of fever, headache, myalgia and symptoms
of upper respiratory tract infection. She had no other skin lesions,
history of caustic ingestion or irradiation. She did not have a
history of diabetes. She was afebrile and hemodynamically
stable. Her general and systemic examination was unremarkable
apart from mild dehydration. She was admitted for her
complains of odynophagia.
She received intravenous fluids and underwent an upper
gastrointestinal endoscopy the next morning. The gastrointestinal
endoscopy revealed a kissing oesophageal ulcer at the level of
the aortic arch (Fig. 1). The rest of the oesophagus and stomach
was unremarkable. She was prescribed a course of proton pump
inhibitors. The symptoms improved over the next day and she
was started on clear feeds. This was progressed to a normal diet
the following day. Her symptoms gradually improved and she
was discharged home on the third day. The histology of the
ulcer revealed acute erosive oesophagitis (Fig. 2). The histology
was negative for cytomegalovirus and there was no evidence of
malignancy. Naranjo score of seven confirmed this case to be a
probable adverse drug reaction rather than due to other factors. 3
Discussion

Department of Surgery, Tan Tock Seng Hospital, Singapore

Received: 23.04.2009; Revised: 15.06.2009; Accepted: 16.06.2009 Drug induced oesophageal disease is a common condition

JAPI january 2011 VOL. 59 57


Fig. 1 : Kissing oesophageal ulcers at the level of aortic arch
Fig. 2 : Photomicrograph showing acute erosive oesophagitis
that is under reported and largely preventable. The incidence
of 3.9 to 4 cases per 1,00,000 populations appear to be very low.4
Doxycycline is commonly prescribed for pelvic inflammatory
disease and acne. Doxycycline induced oesophageal injury is
hence more common in females.
Patient factors have been implicated in the causation of
oesophageal injury. For instance, an elderly patient who takes
multiple medications is at high risk for oesophageal injury. Such
patients may not remember the advice given by pharmacists.
Patient with pre-existing oesophageal diseases such as reflux
oesophagitis, scleroderma or oesophageal motility disorders
also fall into this high-risk group. Our case though, demonstrates
that even young and healthy individuals are not immune to
drug induced injury and there are other factors that are equally
important.
Medication factors play an important role in DIOD. The
manner in which the prescribed drug is ingested is often
overlooked. Medicine taken with less or no water or taken at
bed time may remain in contact with the oesophageal mucosa
for a long duration and can cause direct mucosal injury. There is
decreased salivation and swallowing during sleep and this may
increase the transit time through the oesophagus.
Liquid formulations are less likely to cause oesophageal
58 JAPI january 2011 VOL. 59
Table 1 : Common medicines causing oesophageal injury
with relevant clinical features
Medicine Comments
Antibacterials 4 Accounts for 60% of cases of DIOD.
Commonest antibiotic is doxycycline. A
typical patient is a young female without
any past history of oesophageal disorder
complaining of odynophagia and chest
pain. The capsule form of tetracycline has
also been commonly implicated.
Acetylsalicylic acid 10,11 Can affect any level of the gastrointestinal
tract from the oesophagus to the large
intestine. Accounts for 8% of cases of DIOD.
More than a third of cases have stricture or
haemorrhage.
Alendronate 12,13 Increasingly recognised as a cause of DIOD.
Causes local chemical mucosal damage.
Should be taken early in the morning with
at least 200ml of water.
Potassium chloride 1 Has been associated with massive bleeding
due to erosion through the oesophagus into
the aorta, left atrium or bronchial artery.
Most patients have progressive dysphagia
and little pain, hence presentation is
delayed and strictures are common. Any
oesophageal symptom in a heart disease
patient who is on potassium chloride
should be investigated immediately.
Quinidine 14 Less than twenty cases have been reported.
Gross oedema that develops at the site of
injury can be radiologically confused as a
filling defect similar to malignancy.
Iron formulations 15 The patients are commonly elderly,
bedridden and on polypharmacy.
Oesophageal perforation has also been
reported.
Emepronium bromide 16 This is an anticholinergic used in urinary
conditions. Its local irritant effect can be
compounded by gastroesophageal reflux.
injury compared to tablets. Sustained release formulations may
cause oesophageal injury as they tend to be large in size and
hence difficult to swallow. Gelatin based capsules may stick in
the oesophageal lumen at the sites of anatomical narrowing (eg.
aortic arch) or pathological narrowing (eg. enlarged left atrium)
and can cause local mucosal injury. The chemical nature of the
formulation is also important in the causation of damage. Most of
the oesophagus damaging medicines are acidic and cause direct
toxic effects when they remain in contact with the mucosa for a
long duration. Anticholinergics cause reduced salivation and has
been associated with drug induced oesophageal disease. Table 1
summarises the common medicines that can cause oesophageal
injury and their relevant important clinical details.
Doxycycline can produce a pH of less than three when
dissolved in ten millilitres of water or saliva.5 It is also shown
that doxycycline capsules remain in oesophagus for three times
long as doxycycline tablets.6 Our patient was taking doxycycline
capsules at bed time with minimal water. In a reported series
of eight patients with tetracycline induced oesophagitis, seven
patients were taking the drug in capsule form.7 It is recommended
that such medicines be taken in the sitting or standing position
and with at least 100 millilitres of water. Applegate GR et al have
reported a shorter oesophageal transit time when medication is
swallowed with more liquids.8 Also, it is advisable to remain
upright for at least 15 minutes after the ingestion of medicine.4
Intravenous and liquid formulations of doxycycline have not
been reported to cause oesophageal injury.
The common symptoms of DIOD are dysphagia, odynophagia
and retrosternal chest pain. Patients may also complain of a
foreign body sensation lodged in the throat. The symptoms
start variably after ingestion of medicine and typically get
better within a few days of discontinuing the drug. Diagnostic
endoscopy is unnecessary if the history is typical. It is reserved
for cases where the history is atypical; where symptoms
persist for a long duration of time, presence of a pre-existing
oesophageal disorder, when there is haematemesis or when other
causes of dysphagia are considered as differentials. Endoscopy
is the gold standard and radiological investigations are not
informative in acute drug induced oesophagitis. The common
endoscopic finding is one to several discrete shallow, small
ulcers. Particles of medicine can also be found at the site or ulcer
formation. Our patient had kissing ulcers at the level of aortic
arch and the surrounding mucosa was normal.
DIOD is self-limiting and symptoms usually improve on
discontinuation of the medicine. Our patient already stopped
taking doxycycline after the third day. Proton pump inhibitors
or H2 receptor antagonists have no proven role in the absence
of reflux oesophagitis. Topical protective agents and local
anaesthetics such as liquid sucralfate or lignocaine may be of
benefit for ulcer healing and pain relief. Delayed oesophageal
stricture formation may require endoscopic dilatation.9
DIOD is a common and largely preventable condition. A
detailed history and high index of suspicion is the key to an
accurate diagnosis. If left undiagnosed it can have serious
consequences. The simple advice of swallowing medication
with plenty of water in an upright position can prevent the
consequence of erosive oesophagitis.
Acute Aortic Syndrome- Penetrating Atherosclerotic
Ulcer with contained Rupture Managed by Endovascular
Stent-Grafting
Girish R Sabnis*, Trupti H Trivedi**, Sandhya A Kamath***, Nivedita D Moulick****,
Hemant Deshmukh+, Krantikumar Rathod++
Abstract
We present the case of a hypertensive male who came with acute onset of severe backache and hypotension.
Emergency imaging revealed a penetrating atherosclerotic ulcer of descending thoracic aorta with contained
rupture and bilateral hemothorax. Initially stabilised with medical management, this patient went on to undergo
endovascular stent-grafting. The sequence of clinical events of this uncommon entity and the relatively novel
interventional modality are reviewed.
Introduction
A cute aortic syndrome is the modern term that includes aortic
dissection, intramural hematoma (IMH) and penetrating
Resident PG student, **Associate Professor, ***Professor and Dean,
*
Professor and Head, Dept of Medicine, LTM Medical College and
****
General Hospital, Sion, Mumbai- 400 022; +Professor, ++Associate
Professor, Dept of Radiology, Seth GS Medical College and KEM
Hospital, Parel, Mumbai-400 012
Received: 16.03.2009; Revised: 26.06.2009; Accepted: 27.06.2009
JAPI january 2011 VOL. 59 59
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Lancet 1977;1:424-5.
atherosclerotic ulcer (PAU).1 Classic dissection is caused by a tear
in the intima, commonly preceded by medial wall degeneration
or cystic medial necrosis. Hypertension is the most common risk
factor, with chronic exposure of aortic wall to high shear stress.
Incidence is 2.6 to 3.5 cases per 1,00,000 person-years.2 Men are
affected twice as often as women, with peak incidence in the fifth
and sixth decades. The following case report demonstrates a PAU
complicated by rupture, eventually managed by endovascular
stent grafting, and explores the role of this intervention in