A 58-year-old woman comes to the office due to a week of pain with swallowing. Her symptoms have progressively worsened, and now she cannot eat comfortably. The patient has a history of hypertension, osteoporosis, and primary biliary cholangitis progressing to cirrhosis. She underwent a liver transplant 2 years ago and is on immunosuppressive therapy. She does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. The oropharynx is normal in appearance. Cardiopulmonary examination is unremarkable. The patient has epigastric tenderness with no abdominal distension or guarding. Upper endoscopy shows several small esophageal ulcerations with distinct borders located in the middle and lower portions of the esophagus. A biopsy taken at the edge of an ulcer shows giant cells and intranuclear eosinophilic inclusions. Which of the following is the most appropriate treatment for this patient?

Question

A 58-year-old woman comes to the office due to a week of pain with swallowing.  Her symptoms have progressively worsened, and now she cannot eat comfortably.  The patient has a history of hypertension, osteoporosis, and primary biliary cholangitis progressing to cirrhosis.  She underwent a liver transplant 2 years ago and is on immunosuppressive therapy.  She does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  The oropharynx is normal in appearance.  Cardiopulmonary examination is unremarkable.  The patient has epigastric tenderness with no abdominal distension or guarding.  Upper endoscopy shows several small esophageal ulcerations with distinct borders located in the middle and lower portions of the esophagus.  A biopsy taken at the edge of an ulcer shows giant cells and intranuclear eosinophilic inclusions.  Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

11ec160b_3944_20d8_9249_11905e37db95_MD0001_00 Esophagitis is usually the result of a noninfectious process such as gastroesophageal reflux disease. However, patients with impaired cell-mediated immunity (eg, chemotherapy, post-transplantation, AIDS) are also at risk for esophageal infections. The leading causes are Candida, cytomegalovirus, and herpes simplex virus (HSV). HSV esophagitis usually presents with significant pain and discomfort with swallowing. Endoscopy typically reveals small vesicles or punched-out ulcers (ie, distinct borders) on the esophageal mucosa. Classic HSV findings on biopsy include multinucleated giant cells and eosinophilic intranuclear inclusion bodies (Cowdry type A). Treatment with oral acyclovir usually resolves the active infection, but latent virus can reactivate in the future, leading to recurrent symptoms. (Choice B) Alendronate is a bisphosphonate used in the treatment of osteoporosis. Bisphosphonates can cause medication-induced esophagitis and could worsen this patient's symptoms. (Choice C) Azithromycin can be used as part of the treatment for disseminated mycobacterium avium complex, which often involves the gastrointestinal tract. However, this condition usually occurs in those with advanced AIDS; the esophagus is affected less commonly than the intestine; and endoscopy typically reveals whitish-yellow nodules on the mucosa. (Choice D) Fluconazole is used for candidal esophagitis. Endoscopy would reveal white pseudomembranes on the esophageal mucosa, and histopathology would show yeasts with pseudohyphae. (Choice E) Misoprostol is a prostaglandin analogue that significantly reduces gastric acid secretion and is sometimes used to prevent ulcers due to nonsteroidal antiinflammatory medication. (Choice F) Proton pump inhibitors (eg, omeprazole) are used to treat erosive esophagitis from chronic reflux. Erosive esophagitis typically causes irregular ulcers along the esophageal mucosa, and biopsy would demonstrate inflammatory exudates and fibrinoid necrosis. (Choice G) Tenofovir is an antiviral agent that can be used for HIV and chronic hepatitis B infections. Although tenofovir is an antiviral medication, it is not effective against HSV. Educational objective: Herpes simplex virus esophagitis is most common in those with impaired cell-mediated immunity. Endoscopy typically reveals small vesicles and "punched-out" ulcers. Findings on biopsy usually include multinucleated giant cells and eosinophilic intranuclear inclusions (Cowdry type A inclusion bodies). Acyclovir is the treatment of choice.

A 58-Year-Old Woman Comes to the Office Due to a Week