3039 Esophageal Ulcers: A Presenting Symptom of Acute HIV Infection

Abstract

INTRODUCTION: Dysphagia and odynophagia are commonly encountered in patients who are immunocompromised from chronic Human Immunodeficiency Virus (HIV) infection. Acute HIV infection can also cause odynophagia due to abrupt onset of oropharyngeal mucosal disease. We describe the eventual diagnosis of acute HIV infection in a patient presenting with dysphagia and odynophagia following endoscopic finding of esophageal ulceration. CASE DESCRIPTION/METHODS: A 43-year-old man presented with one week of epigastric pain, dysphagia, and odynophagia in the setting of recent fever (TMax 102.8F) and chills. He had intermittently taken a PPI following an emergency room visit the previous week. Oropharyngeal exam was negative for ulcers or thrush and abdominal exam was benign. Initial labs were normal aside from mild leukopenia (WBC 3,100/uL) with a low absolute neutrophil count. He underwent EGD showing several deep distal esophageal ulcers. Pathology showed acute esophagitis with mild to severe neutrophilic infiltrate and neutrophilic microabscesses. Staining of the ulcer biopsy specimens was negative for cytomegalovirus (CMV), herpes simplex virus (HSV) and fungal elements. The unknown etiology of his esophageal ulcers prompted testing for HIV. HIV immunoassay was positive however antibody differentiation was indeterminate. A subsequent HIV viral load was positive indicating acute HIV-1 infection. He was placed on anti-retroviral therapy soon after. A repeat EGD was performed three months later, demonstrating complete resolution of the previously seen ulcers. DISCUSSION: Presenting signs and symptoms of acute symptomatic HIV infection are nonspecific and the diagnosis is often missed or delayed. Esophageal ulceration may be underrecognized as an acute manifestation of illness. In one study of 16 men presenting with odynophagia who were eventually found to have acute HIV infection (HIV serology negative at presentation), all 16 were found to have esophageal ulceration during index endoscopy. Identification of viral particles resembling HIV-1 within ulcer biopsies with electron microscopy and isolation of HIV-1 from an ulcer biopsy specimen raise the possibility of direct viral infection of esophageal cells. With this in mind, endoscopists and gastroenterology providers should have a high index of suspicion for acute HIV infection in patients with odynophagia secondary to esophageal ulcer of unknown etiology.