HIV-Associated Idiopathic Esophageal Ulcers

Abstract

While thought to be a rare diagnosis and one of exclusion, HIV-associated idiopathic esophageal ulcers may be more prevalent than initially thought. A small study of 51 patients with HIV showed 49% of esophageal ulcers were idiopathic in nature, as opposed to approximately 1.1% in immunocompetent patients.6 Underdiagnosis may be due to lack of endoscopic evaluation in patients with ulcer symptoms as well as high mortality in patients with the degree of immunosuppression needed to develop such ulcers.1 We present the case of a 32-year-old male with no significant past medical history presenting with atypical chest pain. The pain was described as crampy, midsternal pain exacerbated by eating over one month accompanied by dysphagia to solids and liquids. The patient was ruled out for acute coronary syndrome. Initial laboratory testing revealed pancytopenia with eosinophilia and lymphopenia. HIV testing was positive with a CD4 count of 12. He was started empirically on fluconazole for suspected candida esophagitis. After no improvement, an EGD was performed showing numerous ulcers throughout the esophagus with no signs of bleeding. Biopsies were negative for CMV, HSV, fungal infection or neoplasia. The diagnosis of HIV-associated idiopathic esophageal ulcers was made. He was started on prednisone 40mg daily for 1 week with a taper over 1 month, pantoprazole 40mg twice daily and GI cocktails (MaaloxTM, viscous lidocaine, donnatal) for symptomatic relief. Follow-up EGD two months later revealed healing ulcers significantly improved from prior examination. Idiopathic esophageal ulcers in HIV-infected patients may be underdiagnosed and should be considered in patients who presenting with dysphagia and immunosuppression who do not respond to empiric treatment for infectious causes. When found, treatment includes antiretroviral therapy in combination with corticosteroids or thalidomide.2,3 Thalidomide is thought to stimulate the production of T cells, inhibiting HIV by interfering with TNF and mRNA.4 In patients with severe neutropenia, however, thalidomide is not an option and steroids may be used. Although, the mechanism is unknown, steroids have been demonstrated as an effective treatment option.3,5Figure 1Figure 2