A case of black esophagus with histopathologic description and characterization.

To the Editor.—We read with interest the recent case report by Altenburger et al regarding black esophagus. The impressive gross picture of the esophagus reminds us of our previous article entitled ‘‘Intraepithelial Haemorrhage of the Oesophagus: A Terminal Event in Haematological Disorders.’’ 2 In this original article on intraepithelial hemorrhage of the esophagus, all cases revealed the presence of black or redblack lesions in the esophagus, due to hemorrhage, but only black-and-white figures were used in the article. Altenburger et al mentioned the detailed differential diagnoses of black esophagus, including melanosis, pseudomelanosis, coal dust deposition, corrosive ingestion, and acanthosis nigricans. In addition to these diseases and to acute necrotizing esophagitis and malignant melanoma, we would like to add ‘‘intraepithelial hemorrhage of the esophagus’’ as a differential diagnosis of black esophagus. The term black esophagus is more familiar in the field of endoscopy than the field of pathology. Intraepithelial hemorrhage differs from acute necrotizing esophagitis in several ways. Intraepithelial hemorrhage of the esophagus is confined mainly within the epithelium, whereas acute necrotizing esophagitis shows widespread mucosal sloughing and necrosis of the residual mucosa, and extensive submucosal edema. Regarding the location in the esophageal wall and sex predilection, intraepithelial hemorrhage of the esophagus is more often seen in the proximal esophagus and in females, while acute necrotizing esophagitis is usually observed in the distal esophagus, with a slight male predominance. Furthermore, intraepithelial hemorrhage of the esophagus is a terminal event in hematologic disorders, such as acute leukemia, aplastic anemia, myelodysplastic syndrome, and multiple myeloma. On the other hand, the mortality rate ranges from 0% to 38% in cases of acute necrotizing esophagitis, although autopsy cases have been reported. Here we would like to emphasize that black esophagus may be encountered not only in a clinical situation but also in autopsy cases. Intraepithelial hemorrhage should be kept in mind as a differential diagnosis of black esophagus, especially in cases of hematologic disorders.