A 46-year-old homeless man comes to the emergency department with fever and chest pain that worsens with swallowing. The patient has been hospitalized several times recently with Pneumocystis jirovecii pneumonia. He has a history of intravenous drug use. His temperature is 37.8 C (100 F). Oropharyngeal examination is remarkable only for poor dentition. Esophagogastroduodenoscopy is performed and reveals esophageal hyperemia and linear ulcerations. Which of the following is the most likely cause of this patient's condition?
HIV-associated esophagitis | ||
Pathogen | Endoscopic findings | Microscopic findings |
Candida albicans | Patches of adherent, gray/white pseudomembranes on erythematous mucosa | Yeast cells & pseudohyphae invading mucosal cells |
HSV-1 | Small vesicles → | Eosinophilic intranuclear inclusions (Cowdry type A) in multinuclear squamous cells at ulcer margins |
CMV | Linear ulcerations | Intranuclear & cytoplasmic inclusions |
CMV = cytomegalovirus; HSV = herpes simplex virus. | ||
Pneumocystis jirovecii affects almost exclusively immunocompromised individuals; therefore, it is likely that this patient has HIV. He has now developed the painful swallowing characteristic of esophagitis. The 3 main causes of HIV-associated esophagitis are Candida (most common), cytomegalovirus (CMV), and herpes simplex virus (HSV). All can manifest as dysphagia (difficulty swallowing) and/or odynophagia (pain on swallowing) and can be difficult to distinguish clinically; however, accurate diagnosis is essential for treatment. CMV esophagitis is typically characterized endoscopically by large, shallow linear ulcerations (most commonly in the distal esophagus) with intranuclear and cytoplasmic inclusions seen microscopically.
(Choice A) Babesia microti is transmitted by a tick bite and causes babesiosis. It is endemic in the northeastern United States and manifests with flulike symptoms, hepatosplenomegaly, and anemia. It often affects asplenic patients.
(Choice B) Cryptococcosis causes meningitis (not esophagitis) in patients with HIV.
(Choice D) Isospora belli causes profuse watery diarrhea in patients with HIV. It has no role in the development of esophagitis.
(Choice E) In patients with HIV, Toxoplasma gondii causes ring-enhancing brain lesions and chorioretinitis.
(Choice F) Trypanosoma cruzi causes Chagas disease (American trypanosomiasis). Chronic disease leads to cardiomyopathy, achalasia, megacolon, and megaureter.
(Choice G) HSV, not varicella zoster virus (VZV), causes esophagitis in patients with HIV. VZV causes chickenpox (varicella) and shingles (zoster).
Educational objective:
Infectious esophagitis is common in patients with HIV. The most common cause is Candida albicans, although cytomegalovirus and herpes simplex virus are also frequently implicated. Diagnosis is based on endoscopic and microscopic findings.