Acute esophageal necrosis induced by immune checkpoint inhibitors.

A 73-year-old man with chronic obstructive pulmonary disease presented to the emergency department with a two-day history of coffee ground emesis and melena. The patient had been treated with the PD-1 inhibitor nivolumab because of a lung adenocarcinoma stage IV. On examination, he was tachycardic (130 beats per minute) and hypotensive (95/55 mm Hg). Laboratory studies revealed anemia (6.9 g/dL), leukocytosis, and hyper-lactatemia (lactate 6.3 mmol/l). Upper gastrointestinal endoscopy showed diffuse circumferential blackish, necrotic-appearing mucosa of the first third of the esophagus. These findings were consistent with the diagnosis of acute esophageal necrosis (AEN). Biopsy of the esophageal mucosa showed fragments of necrotic tissue with predominant lymphocyte infiltration. The patient was treated with a nothing per mouth diet, total parenteral nutrition, double-dose proton pump inhibitors and broad-spectrum antibiotics (piperacillin/tazobactam). Despite these measures, the patient underwent a progressive clinical deterioration and he died of multiple organ failure 12 days after admission.