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Image challenge – Esophageal stricture: Not your usual culprit?

What caused proton pump inhibitor therapy and repeated dilations to fail in a patient that presented with esophageal dysphagia to solids and liquids?

Gastroenterology image challenge: A 60-year-old woman with past medical history of ATTR amyloidosis and status post heart and liver transplantation presented with complaints of progressive esophageal dysphagia to solids and liquids. She was on tacrolimus, mycophenolate mofetil (MMF) and prednisone. Other pertinent medications included trimethoprim sulfamethoxazole and valganciclovir for infection prophylaxis. Physical examination and laboratory data were unremarkable. Esophagogastroduodenoscopy (EGD) with histopathologic examination of biopsies from the middle third of the esophagus showed the findings presented in figure A and B. Despite high-dose proton pump inhibitor therapy and repeated dilations, symptoms were unchanged and little progress was made in maintaining an increase in luminal diameter.

What is the most likely diagnosis?

To find out the diagnosis, read the full case in Gastroenterology.

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