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For further information, see CMDT Part 15-16: Infectious Esophagitis

Key Features

Essentials of Diagnosis

  • Odynophagia, dysphagia, and chest pain

  • Usually occurs in immunosuppressed patients

  • Endoscopy with biopsy establishes diagnosis

General Considerations

  • Occurs most commonly in immunosuppressed patients with AIDS, solid organ transplants, leukemia, and lymphoma, and in those receiving immunosuppressive drugs

  • Most common pathogens

    • Candida albicans

    • Herpes simplex

    • Cytomegalovirus (CMV)

  • Candida also occurs in patients who have uncontrolled diabetes mellitus and in those receiving systemic corticosteroids, radiation therapy, or systemic antibiotics

Clinical Findings

Symptoms and Signs

  • Odynophagia

  • Dysphagia

  • Substernal chest pain

  • Sometimes asymptomatic (Candida)

  • Oral thrush is present in 75% of patients with candidal esophagitis and 25–50% of patients with viral esophagitis

  • CMV infection at other sites (colon and retina)

  • Oral ulcers (herpes labialis) often associated with herpes simplex esophagitis

Diagnosis

  • Endoscopy with biopsy and brushings (for microbiologic and histopathologic analysis)

Treatment

Medications

  • Treatment may be empiric

Candidal esophagitis

  • Systemic therapy required for suspected (empiric treatment) or proven esophageal candidiasis: fluconazole, 400 mg on day 1, then 200–400 mg/day orally for 14–21 days

  • For patients not responding to empiric fluconazole therapy within 3–5 days, endoscopy with brushing, biopsy, and culture is required to distinguish resistant fungal infection from other infections

  • Candidiasis not responsive to fluconazole may be treated with

    • Itraconazole suspension (not capsules), 200 mg once daily orally

    • Voriconazole, 200 mg twice daily orally

  • Refractory cases may be treated with caspofungin, 50 mg once daily intravenously

CMV esophagitis

  • For initial therapy

    • Ganciclovir, 5 mg/kg every 12 hours intravenously for 3–6 weeks

    • After symptoms resolve, convert to valganciclovir, 900 mg once daily orally

  • For patients with AIDS: immune restoration with antiretroviral therapy is most effective

  • For patients who do not respond or cannot tolerate ganciclovir: foscarnet, 90 mg/kg every 12 hours intravenously for 3–6 weeks

Herpetic esophagitis

  • For patients with a normal immune system: symptomatic treatment

  • For immunocompromised patients

    • Acyclovir, 400 mg five times daily orally, or 250 mg/m2 every 8–12 hours intravenously, usually for 14–21 days

    • Oral famciclovir (500 mg orally three times daily) or valacyclovir (1 g twice daily) are also effective but more expensive than generic acyclovir

  • For nonresponders: foscarnet, 40 mg/kg every 8 hours intravenously for 21 days

Outcome

Prognosis

  • Most patients can be effectively treated with complete symptom resolution

  • Long-term suppressive therapy is sometimes required for immunocompromised patients

When to Refer

  • Refer patients who do not respond to empiric therapy to a gastroenterologist for upper endoscopy, brushings, and biopsy

When to ...

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