Review Question - QID 214719

This patient with poorly controlled HIV (CD4+ count of 50/mm^3) presents with retrosternal chest pain, odynophagia, an endoscopy showing a large linear ulcer, and a biopsy demonstrating intranuclear and intracytoplasmic inclusions. These findings are suggestive of cytomegalovirus (CMV) esophagitis.

CMV esophagitis often affects immunocompromised patients (transplant patients, long-term dialysis, and HIV patients with CD4 count < 100/mm^3) and can present with odynophagia, fever, nausea, epigastric pain, and retrosternal chest pain. It is difficult to distinguish CMV esophagitis from other forms of esophagitis, so diagnosis is confirmed with endoscopy, which typically shows large linear ulcers. Biopsy of the ulcers demonstrating intranuclear and intracytoplasmic inclusions provides further diagnostic support. Treatment is with ganciclovir or foscarnet.

Mehta et al. studied medication adherence in adolescents with eosinophilic esophagitis. The authors found that roughly 20% of adolescents were overdosing on swallowed topical steroids. Nonadherence was not associated with demographic features or symptom severity but was associated with habit strength. The authors recommend that reinforcing habit strength may serve as a productive target for interventions aimed at increasing medication adherence in this population.

Figure/Illustration A is an endoscopy image demonstrating a single, large linear ulcer (black arrow) with relatively normal surrounding mucosa that is characteristic of CMV esophagitis.

Incorrect Answers:
Answer 1: Candida esophagitis similarly presents in immunocompromised patients with odynophagia. However, endoscopy would show white or yellow mucosal plaque-like lesions.

Answer 3: Eosinophilic esophagitis typically affects patients with an atopic triad: atopic dermatitis, asthma, and allergies. Endoscopy would show longitudinal mucosal furrows and fixed esophageal rings, and biopsy would demonstrate extensive eosinophils infiltrating the esophageal mucosa.

Answer 4: Herpes Simplex Virus (HSV) esophagitis similarly presents in immunocompromised patients with odynophagia, retrosternal chest pain, and fever. However, endoscopy would reveal key distinguishing features including vesicles and well-circumscribed, “punched-out” ulcers. Furthermore, a biopsy of the affected tissue would reveal the presence of multinucleated giant cells exhibiting ground-glass nuclei and eosinophilic inclusions.

Answer 5: Medication-induced esophagitis can result from several medications including antibiotics (doxycycline and clindamycin), non-steroidal anti-inflammatory drugs (NSAIDs), bisphosphonates, potassium chloride, and iron. While this patient has a history of acne suggestive of doxycycline use, he no longer takes the medication, and it would be unusual for symptoms to arise years after discontinuation of the medication.

Bullet Summary:
CMV esophagitis presents in immunocompromised patients with odynophagia, fever, and retrosternal burning pain and can be distinguished from other causes of esophagitis with endoscopy.