A 35-year-old woman comes to the emergency department with 3 days of burning substernal chest pain and "excruciating" pain with swallowing. She could not eat or drink anything today due to severe pain. She has not had nausea, vomiting, difficulty initiating swallowing, or a sensation of food getting stuck in her throat. The patient has a history of HIV, asthma, and uterine fibroids. Her current medications include atazanavir-ritonavir, tenofovir, emtricitabine, trimethoprim-sulfamethoxazole, azithromycin, and albuterol. She has a history of medication noncompliance but says that she is currently taking all her medications as prescribed. Her most recent CD4 count was 30/mm³. Her temperature is 37.9 C (100.2 F), blood pressure is 108/59 mm Hg, and pulse is 103/min. The patient is thin and somewhat pale. She has significant dental caries, but oral examination is otherwise normal. Cardiopulmonary examination is unremarkable. The abdomen is soft and nontender. Empiric therapy is initiated, and upper gastrointestinal endoscopy is scheduled. Which of the following is the most likely cause of this patient's symptoms?

Question

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Explanation: 11ec25c8_d450_45bd_bc81_05639cf1409b_MD0003_00 Infectious esophagitis is common in patients with advanced HIV, especially with CD4 counts <100/mm³. The most common cause of esophagitis in patients with HIV is Candida albicans (>60% of cases); however, viral esophagitis is more likely than candidal esophagitis in patients (such as this one) who have: ³ Severe odynophagia (pain with swallowing) as the predominant symptom No dysphagia (difficulty swallowing) No thrush The most commonly implicated viruses in viral esophagitis include herpes simplex virus (HSV) and cytomegalovirus (CMV). The diagnosis is generally made on upper gastrointestinal endoscopy with biopsy. HSV usually causes circular or ovoid vesicular and ulcerated lesions. CMV infection typically causes large, linear distal esophageal ulcers. Histopathology and culture confirm the diagnosis. (Choice A) Several features make viral esophagitis more likely than Candida esophagitis in this patient: The large majority of patients with Candida esophagitis have oral thrush (although lack of thrush does not exclude the diagnosis); most have prominent dysphagia rather than odynophagia; and, if present, odynophagia is generally mild to moderate (rather than severe, as in this patient). Symptomatic patients (especially with visible thrush) can be treated empirically for Candida esophagitis with fluconazole; endoscopy is usually performed in those failing treatment. (Choice B) Eosinophilic esophagitis can be seen in patients who have atopic conditions (eg, asthma, seasonal allergies). However, it is an uncommon disorder, and manifestations typically include dysphagia, heartburn, and refractory acid reflux; odynophagia (especially severe) is rare. In addition, symptoms usually develop chronically (months to years) rather than acutely as seen in this patient. (Choice C) Gastroesophageal reflux disease (GERD) typically presents with heartburn, chest pain, and dysphagia. However, odynophagia (especially severe) is not commonly associated with GERD and warrants evaluation for other possible causes. (Choice D) Medication-related chemical esophagitis ("pill esophagitis") can cause acute odynophagia due to direct effects of a medication on esophageal mucosa. Common offending medications include potassium chloride, tetracyclines, bisphosphonates, and nonsteroidal anti-inflammatory drugs. Although other large or multi-pill medications can cause dysphagia, they less commonly cause true pill esophagitis. Educational objective: Infectious esophagitis is a common complication seen in patients with advanced HIV disease. Patients with oral thrush most likely have Candida esophagitis, with viral causes (eg, herpes simplex, cytomegalovirus) being more likely in the setting of severe odynophagia without dysphagia or thrush. The diagnosis is confirmed with upper gastrointestinal endoscopy. References: Diagnosis and management of infectious esophagitis associated with human immunodeficiency virus infection. (http://www.ncbi.nlm.nih.gov/pubmed/12942677)

A 35-Year-Old Woman Comes to the Emergency Department with 3