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Evaluation of the patient with HIV, odynophagia, and dysphagia

Evaluation of the patient with HIV, odynophagia, and dysphagia
Author:
C Mel Wilcox, MD
Section Editor:
Paul E Sax, MD
Deputy Editor:
Milana Bogorodskaya, MD
Literature review current through: Jan 2024.
This topic last updated: Apr 21, 2022.

INTRODUCTION — Patients with human immunodeficiency virus (HIV; PWH) and advanced immunodeficiency are at risk for esophagitis, which can be severe, and require hospitalization if the patient cannot swallow liquids. This topic addresses the evaluation of the PWH and odynophagia and/or dysphagia. The clinical manifestations and treatment of esophageal candidiasis are discussed in detail elsewhere. (See "Esophageal candidiasis in adults" and "Oropharyngeal candidiasis in adults".)

RISK FACTORS — Patients who have not attained immune reconstitution on combination antiretroviral therapy (ART) or who are not taking ART are at risk of developing esophagitis [1]. Those with a CD4 cell count <100 cells/microL are at particularly high risk.

ETIOLOGY — Esophagitis in patients with acquired immunodeficiency syndrome (AIDS) is most often related to Candida infection; less commonly, it represents herpes simplex virus infection, cytomegalovirus infection, or aphthous (idiopathic) ulcers. (See "Overview of Candida infections", section on 'Esophagitis' and "Herpes simplex virus infection of the esophagus" and "Epidemiology, clinical manifestations, and treatment of cytomegalovirus infection in immunocompetent adults", section on 'Gastrointestinal manifestations' and "Recurrent aphthous stomatitis".)

ASSESSMENT — A history of odynophagia (pain with swallowing, typically in the chest) or dysphagia (defined as difficulty with passage of food from the oropharynx through the esophagus) should prompt concern about possible esophagitis. Although the presence of oropharyngeal candidal infection (thrush) is predictive of esophageal involvement in patients with HIV and odynophagia or dysphagia, its absence does not rule it out. In one series, 18 percent of patients with Candida esophagitis did not have thrush [2].

In two prospective studies, Candida esophagitis was detected by endoscopy in up to 64 percent of symptomatic patients [3,4]. If odynophagia rather than dysphagia is the most prominent symptom, Candida esophagitis is less probable. The patient with severe odynophagia without dysphagia or thrush is more likely to have ulcerative esophagitis caused by idiopathic or cytomegalovirus infection. Rarely, esophageal lymphoma may be diagnosed [5].

MANAGEMENT — Most clinicians treat PWH and odynophagia and/or dysphagia (especially if they also have thrush) with an empiric course of fluconazole (100 to 200 mg/day orally after a 200 mg loading dose) prior to proceeding with endoscopy since Candida infection is so common [6]. Improvement in symptoms should be expected within five to seven days. Treatment duration is generally one to two weeks. (See "Oropharyngeal candidiasis in adults" and "Esophageal candidiasis in adults".)

If there is no response to treatment, endoscopy with biopsy is required to establish a specific etiology (picture 1) [2]. In one series, 77 percent of patients failing empiric therapy were found to have esophageal ulcers on subsequent endoscopy [7]. History of the biopsied tissue is more specific than culture because a positive culture alone can be indicative of colonization rather than infection [8].

Conventional barium swallow radiography is not recommended [9]. A randomized trial comparing barium esophagography with endoscopy in symptomatic PWH found endoscopy to be much more sensitive (98 versus 25 percent) for the diagnosis of Candida infection [10]. The radiographic appearance of an esophageal ulcer is not sufficiently specific to distinguish among the various etiologies. Although a multiphasic, double-contrast technique may increase sensitivity [9], endoscopy and biopsy are still required to make a definitive diagnosis. Furthermore, many patients with odynophagia are unable to swallow barium, resulting in an inadequate study.

SUMMARY AND RECOMMENDATIONS

Immunocompromised patients who are not taking antiretroviral therapy (ART) or who have not attained immune reconstitution on ART are at risk of developing esophagitis. Those with a CD4 cell count <100 cells/microL are at particularly high risk. (See 'Risk factors' above.)

Esophagitis in this setting is most often related to Candida infection; less commonly, it represents herpes simplex virus infection, cytomegalovirus infection, or aphthous (idiopathic) ulcers. (See 'Etiology' above.)

A history of odynophagia (pain with swallowing, typically in the chest) or dysphagia (defined as difficulty with passage of food from the oropharynx through the esophagus) should prompt concern about possible esophagitis. (See 'Assessment' above.)

Most clinicians treat patients with HIV and odynophagia and/or dysphagia (especially if they also have thrush) with an empiric course of fluconazole (100 to 200 mg/day orally after a 200 mg loading dose) prior to proceeding with endoscopy since Candida infection is so common. Improvement in symptoms should be expected within five to seven days. Treatment duration is generally one to two weeks. If there is no response to treatment, endoscopy with biopsy is required to establish a specific etiology. (See 'Management' above.)

ACKNOWLEDGMENT — UpToDate gratefully acknowledges John G Bartlett, MD (deceased), who contributed as Section Editor on earlier versions of this topic and was a founding Editor-in-Chief for UpToDate in Infectious Diseases.

  1. Mönkemüller KE, Lazenby AJ, Lee DH, et al. Occurrence of gastrointestinal opportunistic disorders in AIDS despite the use of highly active antiretroviral therapy. Dig Dis Sci 2005; 50:230.
  2. Wilcox CM, Straub RF, Clark WS. Prospective evaluation of oropharyngeal findings in human immunodeficiency virus-infected patients with esophageal ulceration. Am J Gastroenterol 1995; 90:1938.
  3. Connolly GM, Hawkins D, Harcourt-Webster JN, et al. Oesophageal symptoms, their causes, treatment, and prognosis in patients with the acquired immunodeficiency syndrome. Gut 1989; 30:1033.
  4. Bonacini M, Young T, Laine L. The causes of esophageal symptoms in human immunodeficiency virus infection. A prospective study of 110 patients. Arch Intern Med 1991; 151:1567.
  5. Chow DC, B1eikh SH, Eickhoff L, et al. Primary esophageal lymphoma in AIDS presenting as a nonhealing esophageal ulcer. Am J Gastroenterol 1996; 91:602.
  6. Wilcox CM. Short report: time course of clinical response with fluconazole for Candida oesophagitis in patients with AIDS. Aliment Pharmacol Ther 1994; 8:347.
  7. Wilcox CM, Straub RF, Alexander LN, Clark WS. Etiology of esophageal disease in human immunodeficiency virus-infected patients who fail antifungal therapy. Am J Med 1996; 101:599.
  8. Wilcox CM, Rodgers W, Lazenby A. Prospective comparison of brush cytology, viral culture, and histology for the diagnosis of ulcerative esophagitis in AIDS. Clin Gastroenterol Hepatol 2004; 2:564.
  9. Levine MS. Radiology of esophagitis: a pattern approach. Radiology 1991; 179:1.
  10. Connolly GM, Forbes A, Gleeson JA, Gazzard BG. Investigation of upper gastrointestinal symptoms in patients with AIDS. AIDS 1989; 3:453.
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