Acute necrotizing esophagitis (ANE) is a rare and severe form of esophageal inflammation characterized by diffuse mucosal necrosis predominantly involving the distal esophagus. Its etiology is multifactorial and associated with hypoperfusion states, severe infections (pneumonia, sepsis, etc.), and diabetes mellitus, among others. It primarily affects elderly males and presents as upper gastrointestinal bleeding (UGIB) in up to 90% of cases. 

We present the case of a 78-year-old male with poorly controlled diabetes who presented to the emergency department with a 10-day history of odynophagia and dysphagia, without food impaction. Symptoms began concomitantly with a pneumonia episode treated with oral antibiotics. During this period, he also experienced episodes of hypotension.

Upper endoscopy revealed from the proximal esophagus an erythematous mucosa with confluent erosions involving the entire circumference from 20 cm to the cardia, with diffuse black plaques. The duodenal bulb was edematous and erythematous with fibrin-covered erosions. In the first portion of the duodenum, a 10-mm Forrest IIc ulcer was identified. Biopsies were not obtained due to poor tolerance.

The patient was admitted for supportive management and intravenous proton pump inhibitors. Follow-up endoscopy after one week demonstrated near-complete mucosal recovery, with erythematous areas undergoing re-epithelialization and minimal residual sloughing.

Although UGIB is the most common presentation, the presence of acute odynophagia and dysphagia should prompt consideration of this entity in the differential diagnosis. In our case, given the patient’s recent antibiotic use, the initial suspicion was esophageal candidiasis, which can present with similar symptoms; however, ischemia and inflammation in ANE can also produce them. Obtaining biopsies may be useful in cases where diagnostic uncertainty exists.

Patients with ANE benefit from early diagnosis and prompt supportive treatment, along with management of the underlying cause. This typically leads to favorable recovery, with complete or near-complete re-epithelialization of the esophageal mucosa within 1–2 weeks after initiating therapy.