Evaluation of the HIV-infected patient with odynophagia and dysphagia
- C Mel Wilcox, MD
C Mel Wilcox, MD
- Professor of Medicine
- University of Alabama at Birmingham
HIV-infected patients with advanced immunosuppression are at risk for esophagitis, which can be severe, and require hospitalization if the patient cannot swallow any liquids. This topic will address the evaluation of the HIV-infected patient with odynophagia and dysphagia. The treatment of esophageal candidiasis is discussed elsewhere. (See "Treatment of oropharyngeal and esophageal candidiasis".)
RISK FACTORS FOR ESOPHAGITIS
Patients who have not attained immune reconstitution on potent antiretroviral therapy (ART) or who are not taking ART are at risk of developing esophagitis . Patients with a CD4 cell count <100 cells/mm3 are at particularly high risk.
Esophagitis may be due to Candida, herpes simplex virus (HSV), cytomegalovirus (CMV), or aphthous ulcers, although the most common cause is Candida.
HISTORY AND PHYSICAL EXAMINATION
A history of dysphagia or odynophagia should prompt concerns regarding possible esophagitis. Although oropharyngeal thrush often accompanies esophagitis with a positive predictive value of 90 percent , the converse is not always true. In one series, 18 percent of patients with Candida esophagitis did not have oral thrush .
In two prospective studies, Candida esophagitis was detected by endoscopy in up to 64 percent of symptomatic patients [3,4]. If odynophagia rather than dysphagia is the most prominent symptom, candida esophagitis is less probable. The patient with severe odynophagia, without dysphagia or thrush, is more likely to have ulcerative esophagitis, such as herpes simplex virus, rather than Candida species. Rarely, esophageal lymphoma may be diagnosed .
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