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Infectious Esophageal Disorders

By

Kristle Lee Lynch

, MD, Perelman School of Medicine at The University of Pennsylvania

Reviewed/Revised Feb 2024
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Topic Resources

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 patients with HIV or a transplant.

Candida Esophagitis

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 (1 Reference Esophageal infection occurs mainly in patients with impaired host defenses. Primary agents include Candida albicans, herpes simplex virus, and cytomegalovirus. Symptoms are odynophagia... read more Reference ). Alternatives include other azoles (eg, itraconazole, voriconazole, posaconazole) or echinocandins (eg, caspofungin, micafungin, anidulafungin). Topical therapy has no role.

Reference

  • 1. Pappas PG, Kauffman CA, Andes DR, et al: Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 62(4):e1-e50, 2016. doi: 10.1093/cid/civ933

Herpes Simplex Virus Esophagitis and Cytomegalovirus Esophagitis

These infections are equally likely in patients with a transplant, 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 Herpes Simplex Virus (HSV) Infections 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 patients with HIV, 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 oral or IV acyclovir, valacyclovir, or famciclovir. Patients with immunocompromise are usually treated for a longer duration (ie, 14 to 21 days) than those who are not (7 to 10 days).

CMV is usually treated with IV ganciclovir or oral valganciclovir in patients with immunocompromise. Alternatives include foscarnet and cidofovir.

Drugs Mentioned In This Article

Drug Name Select Trade
Diflucan
ONMEL, Sporanox, TOLSURA
VFEND
Noxafil
Cancidas
Mycamine
Eraxis
Sitavig, Zovirax, Zovirax Cream, Zovirax Ointment, Zovirax Powder, Zovirax Suspension
Valtrex
Famvir
Cytovene, Vitrasert, Zirgan
Valcyte, Valcyte Powder
Foscavir
Vistide
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