Reactions 1302 - 22 May 2010

★ SAntineoplastics

Oesophageal stricture (first report fordexamethasone) in infants and children: 4 casereports

Four paediatric patients developed oesophagealstrictures after induction chemotherapy withdexamethasone, daunorubicin, pegaspargase, vincristineand intrathecal methotrexate [dosages and duration oftreatment not stated] for pre-B-cell acute lymphoblasticleukaemia (ALL). The drugs were administered according tothe Medical Research Council UKALL 2003 protocol.

After achieving remission with induction chemotherapy,a 17-month old male infant had systemic candidiasis whichwas treated with antifungals. Two weeks later, hedeveloped persistent dysphagia and vomiting necessitatingtotal parenteral nutrition. Barium swallow revealed a severedistal oesophageal stricture with nominal passage into thestomach. Following unsuccessful oesophageal dilation, theboy underwent oesophageal replacement. Histologicalexamination revealed extensive inflammation of fibrousconnective tissue, with discrete suppurative granulomataand large necrotic areas. Large numbers of yeast wereidentified. The boy received 3 weeks of amphotericin, and arepeat barium swallow showed free flow into the stomachand duodenum.

A 2-year-old girl had a Candida albicans respiratoryinfection during induction chemotherapy which wastreated with caspofungin and fluconazole. She presentedwith worsening vomiting which led to gradual onset ofdysphagia. Barium swallow revealed a distal oesophagealstricture and a dilated proximal oesophagus with limitedpassage into the stomach. Biopsy of the stricture revealedsquamous mucosa with minimal inflammation. Monthlyoesophageal dilations were started and an opengastrostomy was conducted. The girl’s swallowingreturned to normal after 6 months and her symptomsresolved.

An 11-year-old boy had disseminated candidiasis duringinduction chemotherapy, treated with amphotericin andfluconazole. He presented with progressive dysphagia andregurgitation, and was unable to swallow solids. Bariumswallow and gastroesophagoscopy revealed a discretestricture at the lower end of the oesophagus. Inflamedgranulation tissue was noted on a biopsy of a large ulcerproximal to the stricture. The boy received omeprazole andhis symptoms improved.

A 4-year-old boy developed oral candidiasis 3 weeksafter starting chemotherapy. He was treated with a protonpump inhibitor and fluconazole. He presented 3 weekslater with worsening retrosternal pain and vomiting afteringestion of solid food. A moderate stricture at 20 cm wasseen on gastroesophagoscopy, with clinical evidence ofoesophageal candidiasis; C. albicans infection wasconfirmed on biopsy. Oesophageal dilation was performedand the boy’s symptoms improved.Kelly K, et al. Esophageal strictures during treatment for acute lymphoblasticleukemia. Journal of Pediatric Hematology/Oncology 32: 124-7, No. 2, Mar 2010 -Ireland 803014106

» Editorial comment: A search of AdisBase, Medline andEmbase did not reveal any previous case reports ofoesophageal stricture associated with dexamethasone. TheWHO ADR database contained four reports of oesophagealstenosis associated with dexamethasone.

1

Reactions 22 May 2010 No. 13020114-9954/10/1302-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved