A 37-year-old man comes to the office due to dysphagia and pain on swallowing over the past week. He has had frequent episodes of heartburn in the past that were relieved by antacids in the past, but they have not provided relief this time. The patient has a history of intravenous drug abuse and is currently enrolled in an outpatient methadone program. His other medical problems include hepatitis C and HIV infection (last CD4 count was 80 cells/mm³) , for which he has had poor medical follow-up. The patient has a 15-pack-year smoking history and drinks 1 or 2 cans of beer daily.
Blood pressure is 112/67 mm Hg and pulse is 98/min. BMI is 19 kg/m². Examination shows white plaques on the tongue and soft palate; bilateral, bright-red erythematous fissures are present at the angles of the mouth. The patient has 2 firm, mobile, nontender lymph nodes on the left side of his neck. The remainder of the physical examination is unremarkable.
Which of the following is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_981d_cc9d_853d_e9ef664ba704_MD0002_00 This patient with HIV/AIDS with white plaques on his tongue and angular cheilitis has evidence of oral thrush. Odynophagia and thrush in an immunosuppressed patient raise the concern for candidal esophagitis. Candida is the most common cause of esophagitis in patients with HIV, particularly those with a CD4 count <100 cells/mm³ or those noncompliant with antiretroviral therapy. Patients typically experience dysphagia and mild to moderate odynophagia (in contrast to the severe pain seen with cytomegalovirus or herpes simplex virus esophagitis) and often have concurrent oral thrush. However, the absence of thrush cannot rule out candidal esophagitis; one study found that 18% of patients with candidal esophagitis did not have evidence of oropharyngeal thrush. Empiric treatment with 14-21 days of fluconazole is appropriate for patients with thrush and symptoms consistent with candidal esophagitis. Systemic therapy is required; topical therapy (eg, nystatin swish and swallow), which can be considered in patients without HIV who have candidal esophagitis, should never be used to treat candidal esophagitis in patients with HIV due to very high rates of treatment failure (Choice C). If symptoms fail to improve within 72 hours or are atypical (eg, severe pain with no thrush), an esophagogastroduodenoscopy with biopsies and culture should be performed to rule out other causes (Choice E). (Choice A) Barium swallow is often performed in the evaluation of dysphagia but is less useful in odynophagia as it cannot evaluate mucosal details (eg, esophagitis) or obtain biopsies. (Choice B) Extrinsic compression by lymphadenopathy can also cause dysphagia and would be noted on CT scan; however, odynophagia is uncommon. Modest, nontender lymphadenopathy is quite common in advanced HIV. Educational objective: Empiric fluconazole therapy can be considered in patients with HIV who have typical oral thrush and esophageal symptoms. Treatment for Candida esophagitis requires systemic therapy; it should not be treated with topical antifungals. __________ References: Esophageal infections: etiology, diagnosis, and management. (http://www.ncbi.nlm.nih.gov/pubmed/7987618)

A 37-Year-Old Man Comes to the Office Due to Dysphagia