(See also Overview of Esophageal and Swallowing Disorders Overview of Esophageal and Swallowing Disorders The swallowing apparatus consists of the pharynx, upper esophageal (cricopharyngeal) sphincter, the body of the esophagus, and the lower esophageal sphincter (LES). The upper third of the esophagus... read more .)
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, alcohol use disorder, diabetes, undernutrition, cancer, and esophageal motility disorders Esophageal Motility Disorders Esophageal motility disorders involve dysfunction of the esophagus that causes symptoms such as dysphagia, heartburn, and chest pain. (See also Overview of Esophageal and Swallowing Disorders... read more . Additionally, swallowed or inhaled corticosteroids may increase the risk of infectious esophagitis. Candida infection may occur in any of these patients. Herpes simplex virus (HSV) and cytomegalovirus (CMV) infections occur mainly in AIDS and transplant patients.
Patients with Candida Candidiasis (Invasive) Candidiasis is infection by Candida species (most often C. albicans), manifested by mucocutaneous lesions, fungemia, and sometimes focal infection of multiple sites. Symptoms depend on the site... read more esophagitis usually complain of odynophagia and, less commonly, dysphagia Dysphagia Dysphagia is difficulty swallowing. The condition results from impeded transport of liquids, solids, or both from the pharynx to the stomach. Dysphagia should not be confused with globus sensation... read more . 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 orally or IV once a 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.
Herpes simplex virus esophagitis and cytomegalovirus esophagitis
These infections are equally likely in transplant patients, but HSV Herpes Simplex Virus (HSV) Infections Herpes simplex viruses (human herpesviruses types 1 and 2) commonly cause recurrent infection affecting the skin, mouth, lips, eyes, and genitals. Common severe infections include encephalitis... read more esophagitis occurs early after transplantation (reactivation) and CMV Cytomegalovirus (CMV) Infection Cytomegalovirus (CMV, human herpesvirus type 5) can cause infections that have a wide range of severity. A syndrome of infectious mononucleosis that lacks severe pharyngitis is common. Severe... read more esophagitis occurs 2 to 6 months after. Among AIDS patients, CMV is much more common than HSV, and viral esophagitis occurs mainly when the CD4+ count is < 200/mcL. 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 every 8 hours for 7 to 14 days, valacyclovir 1 g orally 3 times a day, or acyclovir 400 mg orally 5 times a day. CMV is treated with ganciclovir 5 mg/kg IV every 12 hours for 14 to 21 days with maintenance at 5 mg/kg IV once a day for immunocompromised patients. Alternatives include foscarnet and cidofovir.