1844 A Case of Idiopathic Esophageal Ulceration as Initial Presentation of Acquired Immune Deficiency Syndrome

Abstract

INTRODUCTION: Esophageal ulceration (EU) is most frequently caused by gastroesophageal reflux disease. However, immunocompromised individuals are particularly susceptible to EU caused by infections including herpes simplex virus (HSV), cytomegalovirus (CMV), and candida species. Furthermore, patients with acquired immunodeficiency syndrome (AIDS) can also develop idiopathic EU even in the absence of infection. CASE DESCRIPTION/METHODS: A 30-year-old male with no significant past medical history presented with 6 months of profound weight loss, odynophagia, dysphagia, and chest pain. He had no history of NSAID use. Symptoms had persisted despite trials of proton pump inhibitors, H2 antagonists, and sucralfate. His physical exam was notable for cachexia and bi-temporal wasting. Esophagogastroduodenoscopy revealed two large hemi-circumferential cratered distal esophageal ulcers separated by a mucosal bridge. Endoscopic ultrasound demonstrated an isoechoic mass in the lower third of the esophagus measuring 1.2 cm in thickness, obliterating the wall layer architecture, along with three enlarged gastro-hepatic lymph nodes. Pathology demonstrated granulation tissue with fibro-inflammatory debris and was negative for malignancy, HSV, and CMV. Fine needle aspiration of one of the enlarged lymph nodes was also negative for malignancy. A contrasted computed tomography scan of the chest, abdomen, and pelvis did not reveal any additional findings. Laboratory evaluation was most notable for worsening leukopenia (WBC count: 3000 cells/μL) and anemia (Hgb: 9.9 g/dL). Further history revealed unprotected sexual encounters with multiple females in the last 10 years. Subsequent workup demonstrated a positive human immunodeficiency virus (HIV) antibody screen with a CD4 count of 44 cells/µL. Patient was ultimately diagnosed with idiopathic EU from AIDS and was initiated on highly active antiretroviral therapy. DISCUSSION: While EU is a common complication in patients with AIDS, it is normally associated with infections such as CMV and HSV. Idiopathic EU in these patients are rarer and typically found in those with CD4 cell counts less than 100 cells/µL. Our case was unique in that the patient's development of large EU was his initial presentation of AIDS. In these cases, establishing the correct diagnosis and ruling out malignancy is important as misdiagnosis can significantly alter treatment plan and prognosis. This case further highlights the necessity for HIV testing in patients who present with idiopathic EU.