A case of cytomegalovirus esophagitis during topical steroid therapy for eosinophilic esophagitis

Systemic immune deficiency is a major cause of cytomegalovirus (CMV) esophagitis. We report a case of CMV esophagitis during topical steroid therapy of eosinophilic esophagitis (EoE) in a non-immunodeficient patient. An 85-year-old man with dysphagia was on a 6-year regimen of oral budesonide (1200 mcg daily) for EoE. He underwent right upper lobectomy and postoperative radiotherapy 25 years ago for lung squamous cell carcinoma. Esophageal cicatricial stenosis due to EoE or previous radiation therapy persisted. Esophagogastroduodenoscopy revealed ulcerating mucosa with a thick white coat originating from the fixed stenotic lesion to the oral side. Histopathological examinations revealed CMV esophagitis. All signs of CMV esophagitis rapidly disappeared after reducing the budesonide dose and initiating anti-viral treatment with ganciclovir and valganciclovir for 12 and 2 days, respectively. The patient continued topical budesonide 400 mcg daily after anti-viral therapy. The clinical course was uneventful and without CMV esophagitis recurrence. This suggests that topical steroid therapy, particularly the local stasis of steroids at stenotic lesions, may induce CMV esophagitis. This is the first report of CMV esophagitis complicating the local steroid therapy of EoE with a stenotic lesion. When EoE patients' clinical symptoms worsen with topical steroid therapy, CMV esophagitis should be considered.