University of Massachusetts Medical School - Baystate Springfield, MA, United States
Spencer C. Knox, MD, Kartikeya Tripathi, MD, Yesenia Greeff, MD University of Massachusetts Medical School - Baystate, Springfield, MA
Introduction: Dysphagia impacts 1 in 6 adults over the course of their lifetime. Quality of life is diminished, with an average of 12 lost workdays per annum. We report a patient with dysphagia in the setting of HIV/AIDS, diagnosed with HIV-associated idiopathic esophageal ulcers (IEUs). With advances in antiretroviral therapy (ART), IEUs are no longer as common as they once were. This case highlights the importance of an accurate and timely diagnosis.
Case Description/Methods: A 46-year-old woman with HIV/AIDS (CD4 count 71 cells/mm3) presented with two weeks of difficulty swallowing and chest pain. Physical exam revealed a malnourished woman. Labs revealed leukopenia and anemia, WBC 1.2 k/mm3 and Hgb 11.5 g/dL, with an absolute CD4 count of 29 cells/mm3.
Upper endoscopy revealed several large 2-3 cm discrete “punched-out” esophageal ulcers with normal intervening mucosa in the mid-esophagus; the largest ulcer was sampled. Empiric CMV treatment with ganciclovir was initiated. Pathology reported nonspecific inflammatory changes, and no viral cytopathic inclusions or fungal organisms. A working diagnosis of CMV esophagitis was made. Due to worsening neutropenia (nadir 0 cells/mm3), ganciclovir was stopped. Workup for histoplasma, syphilis, and tuberculosis was negative.
Upper endoscopy with biopsies was performed one week later with no new findings. She was diagnosed with HIV-associated idiopathic esophageal ulcers (IEUs), prescribed ART regimen, and prednisolone 40 mg, tapered over four weeks. She reported significant symptom improvement.
Discussion: Odynophagia and dysphagia were commonly reported in up to ⅓ of all patients throughout the course of HIV disease. With the advent of ART, the incidence of HIV-related esophageal pathology has fallen dramatically. HIV-associated IEUs are indistinguishable from CMV esophagitis; both entities are capable of impressive “punched-out” ulcerations. IEUs occur in approximately 10% of patients with HIV, when accounting for people with acute retroviral syndrome or severely depressed CD4 counts. IEUs typically occur when the CD4 count is less than 50 cells/mm3.
Diagnostic criteria include all of the following: endoscopic ulcer confirmed by histopathologist, no evidence of viral cytopathic effect, and no clinical evidence of gastroesophageal reflux or pill-induced esophagitis.
Response rate to steroids can be 92-96%. Alternatively, thalidomide 200 mg orally daily for a 28-day course is effective. Complete resolution of symptoms with thalidomide was seen in 73% of patients.
Figure: Figure 1 Index upper endoscopy, revealing one of several punched-out large non-bleeding esophageal ulcers in the middle third of the esophagus. Cytology brush, also pictured. Figure 2 Middle third of esophagus with discrete deep ulcers and normal-intervening mucosa. Figure 3 Barium esophagram showing several cratered, communicating wall defects in the mid- and lower-third esophagus. Image obtained following four week treatment of prednisolone. Figure 4 Endoscopic view of middle third of esophagus, healing ulcer with scar tissue (post-treatment).
Disclosures: Spencer Knox indicated no relevant financial relationships. Kartikeya Tripathi indicated no relevant financial relationships. Yesenia Greeff indicated no relevant financial relationships.
Spencer C. Knox, MD, Kartikeya Tripathi, MD, Yesenia Greeff, MD. P1413 - Giant HIV-Associated Idiopathic Esophageal Ulcers: A Mimicker of CMV Esophagitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.