A 35-year-old man comes to the office due to a week of pain with swallowing and a substernal burning sensation. The patient was diagnosed with HIV 2 years ago. He was previously noncompliant with treatment but recently started taking antiretroviral therapy and trimethoprim-sulfamethoxazole. CD4 count a month ago was 46/mm³. Temperature is 36.6 C (98 F), blood pressure is 133/89 mm Hg, and pulse is 72/min. Examination of the oral cavity shows white plaques on the buccal mucosa and palate that are easily removable with a tongue scraper. The lungs are clear to auscultation. The abdomen is soft and nontender. What is the most appropriate next step in management of this patient's substernal chest pain?

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11ec25c8_d44f_a97c_bc81_f15f369ddda1_MD0003_00 This patient with AIDS has pain with swallowing, substernal burning, and oral thrush (white oral plaques), indicating likely Candida albicans esophagitis. Infectious esophagitis is common in patients with advanced AIDS (CD4 count <100/mm³). Most cases are caused by C albicans, herpes simplex virus (HSV), or cytomegalovirus (CMV). Although all generally cause progressive pain with swallowing and substernal burning, the presence of concurrent oral thrush usually indicates C albicans infection and should prompt empiric treatment with oral fluconazole. Patients who do not respond to empiric treatment or do not have oral thrush at presentation often require further evaluation with upper endoscopy and biopsy to identify alternate causes (Choice B). HSV esophagitis is usually marked by endoscopic evidence of small, round-oval, volcano-like esophageal lesions and multinucleated giant cells/intranuclear inclusions on biopsy; acyclovir/valacyclovir is the treatment of choice (Choice D). CMV esophagitis is generally marked by large, linear ulcers in the distal esophagus and biopsy evidence of intracytoplasmic and intranuclear inclusions; IV ganciclovir is the treatment of choice. Neither HSV nor CMV esophagitis is generally treated empirically. (Choice A) Barium esophagram is often normal in patients with candidal esophagitis, although many will have small ulcers similar to those seen in viral esophagitis. Barium esophagram will neither confirm nor exclude the diagnosis. (Choice E) Although many medications (eg, potassium supplements, tetracyclines, bisphosphonates) can cause esophagitis due to a direct chemical effect on the esophageal mucosa ("pill esophagitis"), antiretroviral drugs are not common culprits. Therefore, therapy should be continued during the evaluation to reduce the risk of developing HIV drug resistance (particularly because candidal esophagitis is quite likely in the setting of oral thrush). Educational objective: Patients with AIDS are at high risk for infectious esophagitis with Candida albicans (most common), herpes simplex virus, and cytomegalovirus. Patients with concurrent oral thrush are generally treated with empiric oral fluconazole. Those who do not respond to fluconazole or have no evidence of thrush often require further evaluation with upper endoscopy and biopsy to clarify the diagnosis. References: Invasive oesophageal candidiasis: current and developing treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/12699400)

A 35-Year-Old Man Comes to the Office Due to a Week