Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 15-16: Infectious Esophagitis + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ ++ Endoscopy with biopsy and brushings (for microbiologic and histopathologic analysis) + Treatment Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Admit ++ Severe odynophagia with inability to take adequate oral liquids + References Download Section PDF Listen +++ + +Daniell HW. Acid suppressing therapy as a risk factor for Candida esophagitis. Dis Esophagus. 2016 Jul;29(5):479–83. [PubMed: 25833302] + +Grossi L et al. Esophagitis and its causes: who is "guilty" when acid is found "not guilty"? World J Gastroenterol. 2017 May 7;23(17):3011–6. [PubMed: 28533657] + +Hoversten P et al. Infections of the esophagus: an update on risk factors, diagnosis, and management. Dis Esophagus. 2018 Dec 1;31(12). [PubMed: 30295751]