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Infectious Esophageal Disorders

By Kristle Lee Lynch, MD, Assistant Professor of Medicine, Perelman School of Medicine at The University of Pennsylvania

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Esophageal infection occurs mainly in patients with impaired host defenses. Primary agents include Candida albicans, herpes simplex virus, and cytomegalovirus. Symptoms are odynophagia and chest pain. Diagnosis is by endoscopic visualization and culture. Treatment is with antifungal or antiviral drugs.

Esophageal infection is rare in patients with normal host defenses. Primary esophageal defenses include saliva, esophageal motility, and cellular immunity. Thus, at-risk patients include those with AIDS, organ transplants, alcoholism, diabetes, undernutrition, cancer, and esophageal motility disorders. Candida infection may occur in any of these patients. Herpes simplex virus (HSV) and cytomegalovirus (CMV) infections occur mainly in AIDS and transplant patients.

Candida esophagitis

Patients with Candida esophagitis usually complain of odynophagia and, less commonly, dysphagia. About  two thirds of patients have signs of oral thrush (thus its absence does not exclude esophageal involvement). Patients with odynophagia and typical thrush may be given empiric treatment, but if significant improvement does not occur in 5 to 7 days, endoscopic evaluation is required. Barium swallow is less accurate.

Treatment of Candida esophagitis is with fluconazole 200 to 400 mg po or IV once/day for 14 to 21 days. Alternatives include other azoles (eg, itraconazole, voriconazole, posaconazole) or echinocandins (eg, caspofungin, micafungin, anidulafungin). Topical therapy has no role.

HSV and CMV esophagitis

These infections are equally likely in transplant patients, but HSV occurs early after transplantation (reactivation) and CMV occurs 2 to 6 mo after. Among AIDS patients, CMV is much more common than HSV, and viral esophagitis occurs mainly when the CD4+ count is < 200/μL. Severe odynophagia results from either infection.

Endoscopy, with cytology or biopsy, is usually necessary for diagnosis. HSV is treated with IV acyclovir 5 mg/kg q 8 h for 7 days or valacyclovir 1 g po tid. CMV is treated with ganciclovir 5 mg/kg IV q 12 h for 14 to 21 days with maintenance at 5 mg/kg IV 5 days/wk for immunocompromised patients. Alternatives include foscarnet and cidofovir.

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