Esophagitis, Infectious

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

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

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

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

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