A 48-year-old man comes to the emergency department due to 3 days of progressively worsening retrosternal burning chest pain, dysphagia, and odynophagia. His medical problems include hypertension and end-stage renal disease. He underwent cadaveric renal allograft transplantation 8 months ago. The patient's temperature is 38.3 C (101 F), blood pressure is 130/80 mm Hg, and pulse is 94/min. His BMI is 31 kg/m². The oral mucosa is pink and moist without ulcerations. Cardiopulmonary examination is normal. The abdomen is soft with mild epigastric tenderness. The patient's leukocyte count is 4,200/mm³. An esophagogastroduodenoscopy demonstrates linear, shallow ulcerations in the lower esophagus. Which of the following is most likely to be seen on esophageal biopsy?

Question

Quizplus · Accepted Answer

This patient's presentation suggests cytomegalovirus (CMV) esophagitis, which can occur in immunocompromised patients (eg, HIV, transplant, on immunosuppressant drugs). CMV can be transmitted to transplant recipients from the donor organ, or infection can occur subsequently due to chronic immunosuppression. Patients can be asymptomatic or develop a viral prodrome (eg, fever, malaise, myalgias) before organ involvement (eg, esophagitis, pneumonitis, colitis). CMV esophagitis usually presents with odynophagia (pain with swallowing) or dysphagia (difficulty swallowing) that can be accompanied by fever or burning chest pain. Endoscopy typically shows linear and shallow ulcerations in the lower esophagus that sometimes diffusely involve the esophagus. Tissue biopsy usually shows enlarged cells with basophilic or eosinophilic intranuclear inclusion bodies. (Choice B) Metaplastic columnar epithelium is seen in Barrett esophagus, which is usually due to prolonged gastroesophageal reflux disease (GERD). Histology typically shows tongue-like projections of columnar epithelium with goblet cells (ie, intestinal metaplasia) extending from the distal esophagus to the gastroesophageal junction. The absence of chronic GERD symptoms in this patient makes this less likely. (Choice C) A Mallory-Weiss tear typically presents with hematemesis in association with chest or epigastric pain after repeated retching or vomiting; histology will show a mucosal tear without acute inflammation. (Choice D) Helicobacter pylori is a urease-producing organism that can be associated with gastritis and gastric or duodenal ulcers. It usually does not cause significant esophageal disease. (Choice E) Cryptococcus neoformans is a yeast with a polysaccharide capsule. Although disseminated cryptococcosis can occur in immunocompromised patients and involve almost any organ, localized esophageal involvement is more characteristic of Candida (a yeast without a polysaccharide capsule). Educational objective: Cytomegalovirus esophagitis can occur in transplant patients and usually presents with odynophagia or dysphagia that can be accompanied by fever or burning chest pain. Endoscopy typically shows linear and shallow ulcerations in the lower esophagus, and histology usually shows enlarged cells with intranuclear inclusions.

A 48-Year-Old Man Comes to the Emergency Department Due to 3