Esophageal infection occurs mainly in patients with impaired host defenses. Primary agents include Candida albicans, herpes simplex virus, and cytomegalovirus. Symptoms are odynophagia and chest pain. Diagnosis is by endoscopic visualization and culture. Treatment is with antifungal or antiviral medications.
(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 patients with HIV or a transplant.
Candida Esophagitis
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.
Image provided by Kristle Lynch, MD.
Treatment of Candida1
Reference
1. Pappas PG, Kauffman CA, Andes DR, et al: Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 62(4):e1-e50, 2016. doi: 10.1093/cid/civ933
Herpes Simplex Virus Esophagitis and Cytomegalovirus Esophagitis
These infections are equally likely in patients with a transplant, but HSV esophagitis occurs early after transplantation (reactivation) and CMV esophagitis occurs 2 to 6 months after. Among patients with HIV, 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.
Image provided by David M. Martin, MD.
Endoscopy, with cytology or biopsy, is usually necessary for diagnosis.
