A 32-year-old man comes to the office due to burning pain in his chest and severe midsternal pain on swallowing over the past week. The symptoms have become so severe that he cannot swallow any food or fluids. The patient has also felt warm for the past 2 days but has had no dyspnea, cough, abdominal pain, diarrhea, or urinary symptoms. He has a history of intravenous drug abuse and a recent episode of community-acquired pneumonia. The patient also has chronic HIV infection (last CD4 count was 90 cells/mm³) but has had poor medical follow-up. He has smoked a pack of cigarettes daily for 15 years and drinks 1 or 2 cans of beer daily.
Temperature is 38 C (100.4 F) , blood pressure is 112/67 mm Hg, pulse is 98/min, and respirations are 16/min. Oxygen saturation is 97% on room air. BMI is 19 kg/m². The patient is in distress due to pain. Examination shows no oral lesions. The chest is clear to auscultation. No murmurs are noted. The remainder of the physical examination is unremarkable.
Which of the following is the most appropriate next step in management of this patient?

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Quizplus · Accepted Answer

11ec193a_97ed_bc7e_853d_53b740dacbe4_MD0002_00 This patient with HIV/AIDS has odynophagia, raising concern for infectious esophagitis, particularly given his CD4 count <100 cells/mm³ and noncompliance with antiretroviral therapy. Candida albicans, the most common cause of infectious esophagitis in immunosuppressed patients, typically presents with moderate odynophagia, dysphagia, and concurrent oral thrush. Patients with these classic features may be given an empiric trial of systemic antifungals (eg, oral fluconazole). ³ However, the presence of severe odynophagia without evidence of thrush favors ulcerative esophagitis; retrosternal pain and fevers can also occur, as seen in this patient. Ulcerative esophagitis is commonly due to viral infections. Herpes simplex virus esophagitis, which often occurs with concurrent herpetic outbreaks elsewhere (eg, herpes labialis), can lead to bleeding and tracheoesophageal fistula formation. Cytomegalovirus esophagitis often occurs with concurrent retinitis, which can lead to blindness. As a result, severe odynophagia, fevers, and the absence of classic candidal esophagitis symptoms should prompt endoscopy with biopsy and culture rather than a trial of empiric fluconazole to ensure correct diagnosis (Choice C). Endoscopy would also help identify the 18% of cases of Candida esophagitis not associated with thrush as well as exclude malignancy as the cause of this patient's presentation. (Choice A) Barium swallow is useful in the evaluation of dysphagia but is less useful in evaluation of odynophagia in immunosuppressed patients as it has low sensitivity for mucosal lesions and cannot be used to obtain culture or tissue specimens. (Choice B) Clotrimazole troches (lozenges) are used for uncomplicated thrush but have a high failure rate for esophagitis. If this patient is found to have Candida esophagitis, systemic antifungals are required. (Choice D) Proton pump inhibitors do not help candidal/viral esophagitis. Given the high incidence of opportunistic infections in patients with advanced HIV, endoscopy (rather than an empiric proton pump inhibitor trial) should be performed. Educational objective: Empiric fluconazole therapy can be considered in patients with HIV who have typical oral thrush and esophageal symptoms. However, endoscopy is indicated for those with severe odynophagia and fevers, especially if they do not have thrush. __________ References: Esophageal infections: etiology, diagnosis, and management. (http://www.ncbi.nlm.nih.gov/pubmed/7987618)

A 32-Year-Old Man Comes to the Office Due to Burning