Internal Medicine

P1: OXT/OZN/JDO P2: PSB

0521779407-E-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:10

Esophageal Infections and Inflammation 553

■biopsy any esophageal ulcers and send for viral culture

■endoscopic appearance

➣Candida esophagitis – small, yellow-white raised plaques with

surrounding erythema in mild disease; confluent linear and

nodular plaques reflect extensive disease

➣HSV esophagitis – vesicles and small, discrete, punched-out

(“volcano-like”) superficial ulcerations with or without a fibri-

nous exudate. In later stages, a diffuse erosive esophagitis devel-

ops from enlargement and coalescence of the ulcers

➣CMV esophagitis – serpiginous ulcers in an otherwise normal

mucosa that may coalesce to form giant ulcers, particularly in

the distal esophagus

➣endoscopy is not helpful in patients post-radiation and will

increase patient discomfort

Imaging

■not recommended as initial test

➣inability to perform biopsies

➣odynophagia limits ability to drink barium

■findings on barium esophagram:

➣candidiasis: diffuse plaque-like lesions, linear configuration

➣HSV: stellate focal ulcers on background of normal mucosa

➣CMV: linear vertical ulcerations with central umbilication; large

(>2 cm) and deep in AIDS patients

➣idiopathic HIV-associated ulcer: large, isolated, deep ulcers

differential diagnosis

■infectious etiologies: Candida, CMV, HSV, varicella zoster, HIV, TB

■differential diagnosis dependent on underlying condition:

➣normal host: HSV or candidiasis in the elderly

➣post-transplantation patients: Candida, CMV, HSV, or VZ

➣malnutrition, corticosteroid usage, diabetes mellitus: candidia-

sis

■idiopathic esophageal ulcer associated with HIV infection

■pill-induced esophagitis: one or more discrete ulcers in junction of

proximal and middle third of the esophagus

■gastroesophageal reflux disease

■esophageal motility disorder, such as achalasia

■esophageal cancer

■rare: Crohn’s disease, histoplasmosis, syphilis, sarcoidosis, bacterial

esophagitis