Infectious Esophageal Disorders
(See also Overview of Esophageal and Swallowing Disorders.)
Esophageal infection is rare in patients with normal host defenses. Primary esophageal defenses include saliva, esophageal motility, and cellular immunity. Thus, at-risk patients include those with AIDS, organ transplants, alcohol use disorder, diabetes, undernutrition, cancer, and esophageal motility disorders. Additionally, swallowed or inhaled corticosteroids may increase the risk of infectious esophagitis. Candida infection may occur in any of these patients. Herpes simplex virus (HSV) and cytomegalovirus (CMV) infections occur mainly in AIDS and transplant patients.
Patients with Candida esophagitis usually complain of odynophagia and, less commonly, dysphagia. About two thirds of patients have signs of oral thrush (thus its absence does not exclude esophageal involvement). Patients with odynophagia and typical thrush may be given empiric treatment, but if significant improvement does not occur in 5 to 7 days, endoscopic evaluation is required. Barium swallow is less accurate.
Treatment of Candida esophagitis is with fluconazole 200 to 400 mg orally or IV once a day for 14 to 21 days. Alternatives include other azoles (eg, itraconazole, voriconazole, posaconazole) or echinocandins (eg, caspofungin, micafungin, anidulafungin). Topical therapy has no role.
These infections are equally likely in transplant patients, but HSV esophagitis occurs early after transplantation (reactivation) and CMV esophagitis occurs 2 to 6 months after. Among AIDS patients, CMV is much more common than HSV, and viral esophagitis occurs mainly when the CD4+ count is < 200/mcL. Severe odynophagia results from either infection.
Endoscopy, with cytology or biopsy, is usually necessary for diagnosis.
HSV is treated with IV acyclovir 5 mg/kg every 8 hours for 7 to 14 days, valacyclovir 1 g orally 3 times a day, or acyclovir 400 mg orally 5 times a day. CMV is treated with ganciclovir 5 mg/kg IV every 12 hours for 14 to 21 days with maintenance at 5 mg/kg IV once a day for immunocompromised patients. Alternatives include foscarnet and cidofovir.