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ESSENTIALS OF DIAGNOSIS

  • Immunosuppressed patient.

  • Odynophagia, dysphagia, and chest pain.

  • Endoscopy with biopsy establishes diagnosis.

GENERAL CONSIDERATIONS

Infectious esophagitis occurs most commonly in immunosuppressed patients. Patients with AIDS, solid organ transplants, leukemia, lymphoma, and those receiving immunosuppressive drugs are at particular risk for opportunistic infections. Candida albicans, herpes simplex, and CMV are the most common pathogens. Candida infection may occur also in patients who have uncontrolled diabetes and those being treated with systemic corticosteroids, radiation therapy, or systemic antibiotic therapy. Herpes simplex can affect normal hosts, in which case the infection is generally self-limited.

CLINICAL FINDINGS

A. Symptoms and Signs

The most common symptoms are odynophagia and dysphagia. Substernal chest pain occurs in some patients. Patients with candidal esophagitis are sometimes asymptomatic. Oral thrush is present in only 75% of patients with candidal esophagitis and 25–50% of patients with viral esophagitis and is therefore an unreliable indicator of the cause of esophageal infection. Patients with esophageal CMV infection may have infection at other sites such as the colon and retina. Oral ulcers (herpes labialis) are often associated with herpes simplex esophagitis.

B. Special Examinations

Treatment may be empiric. For diagnostic certainty, endoscopy with biopsy and brushings (for microbiologic and histopathologic analysis) is preferred because of its high diagnostic accuracy. The endoscopic signs of candidal esophagitis are diffuse, linear, yellow-white plaques adherent to the mucosa (eFigure 15–34). CMV esophagitis is characterized by one to several large, shallow, superficial ulcerations (eFigure 15–35). Herpes esophagitis results in multiple small, deep ulcerations (eFigure 15–36).

eFigure 15–34.

Candida esophagitis in a patient who presented with dysphagia. Note the whitish well-circumscribed lesions and confluent creamy plaques in the mid- esophagus (Used, with permission, from Michelle Nazareth, MD.)

eFigure 15–35.

Cytomegalovirus esophagitis. (Used, with permission, from John Cello, MD.)

eFigure 15–36.

Herpes esophagitis. In herpes esophagitis, typically ulcers are seen in the mid- to distal esophagus. These ulcers are whitish lesions that are umbilicated with areas of central clearing. (Used, with permission, from Michelle Nazareth, MD.)

TREATMENT

A. Candidal Esophagitis

Systemic therapy is required for esophageal candidiasis (see eFigure 15–34). An empiric trial of antifungal therapy is often administered without performing diagnostic endoscopy. Initial therapy is generally with fluconazole, 400 mg on day 1, then 200–400 mg/day orally for 14–21 days. Patients not responding to empiric therapy within 3–5 days should undergo endoscopy with brushings, biopsy, and culture to distinguish resistant fungal infection from other infections (eg, CMV, herpes). Esophageal candidiasis not responding to fluconazole ...

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