Sarcina ventriculi as an Unknown Culprit for Esophageal Stricturing

A 65-year-old woman with metastatic breast cancer and a history of Schatzki ring presented with 2 months of progressive dysphagia. Imaging with x-ray fluoroscopy revealed an irregularly short segment stricture at the mid to distal esophagus. Esophagogastroduodenoscopy (EGD) showed a benign-appearing stenosis with a single 7-mm nodule at the gastroesophageal junction and non-bleeding gastric ulcers in the setting of residual food in the stomach (Figure 1). She underwent subsequent dilation 6 days later under fluoroscopy with a Savary dilator up to 12 mm, and she was medically managed with a proton pump inhibitor. Esophageal and gastric biopsies revealed acute and chronic inflammation with rare large tetrads of bacterial cocci, morphologically consistent with Sarcina ventriculi (Figure 2). In light of S. ventriculi presence, she was treated with 7 days of metronidazole and ciprofloxacin. An esophageal stent was placed 1 week after initial dilation failed to improve symptoms. Unfortunately, her hospital course was complicated by hemorrhagic gastropathy secondary to therapeutic heparin in the setting of a pulmonary embolism, which resulted in stent removal 2 weeks after initial placement. Ultimately, the patient was transitioned to palliative comfort care due to overall poor prognosis