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Evaluation of the HIV-infected patient with odynophagia and dysphagia

C Mel Wilcox, MD
Section Editor
John G Bartlett, MD
Deputy Editor
Howard Libman, MD, FACP


HIV-infected patients with advanced immunodeficiency are at risk for esophagitis, which can be severe, and require hospitalization if the patient cannot swallow liquids. This topic addresses the evaluation of the HIV-infected patient with odynophagia and/or dysphagia. The clinical manifestations and treatment of esophageal candidiasis are discussed in detail elsewhere. (See "Clinical manifestations of oropharyngeal and esophageal candidiasis" and "Treatment of oropharyngeal and esophageal candidiasis".)


Patients who have not attained immune reconstitution on potent antiretroviral therapy (ART) or who are not taking ART are at risk of developing esophagitis [1]. Those with a CD4 cell count <100 cells/microL are at particularly high risk.


Esophagitis in patients with AIDS is most often related to Candida infection; less commonly, it represents herpes simplex virus (HSV) infection, cytomegalovirus (CMV) infection, or aphthous ulcers. (See "Overview of Candida infections", section on 'Esophagitis' and "Herpes simplex virus infection of the esophagus" and "Epidemiology, clinical manifestations, and treatment of cytomegalovirus infection in immunocompetent adults", section on 'Gastrointestinal manifestations' and "Recurrent aphthous stomatitis".)


A history of odynophagia (pain with swallowing, typically in the chest) or dysphagia (defined as difficulty with passage of food from the oropharynx through the esophagus) should prompt concern about possible esophagitis. Although the presence of oropharyngeal candidal infection (thrush) is predictive of esophageal involvement in HIV-infected patients with odynophagia or dysphagia, its absence does not rule it out. In one series, 18 percent of patients with Candida esophagitis did not have thrush [2].

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 caused by HSV or CMV infection. Rarely, esophageal lymphoma may be diagnosed [5].

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Literature review current through: Nov 2017. | This topic last updated: Oct 19, 2017.
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