Infectious esophagitis

Infectious esophagitis

Infectious esophagitis

Esophagitis is a general term for any inflammation, irritation, or swelling of the esophagus. Esophagitis can cause painful, difficult swallowing and chest pain. The esophagus is the tube that connects the back of your throat to your stomach. Food and liquid go down the tube when you swallow. The lining of the esophagus is sensitive. Because of this, many things can cause irritation. The most common cause is acid from the stomach. But an infection from fungi, yeast, a virus, or bacteria can also cause irritation. This is called infectious esophagitis.

Infectious esophagitis occurs most commonly in immuno­suppressed patients. Patients with AIDS, solid organ trans­plants, leukemia, lymphoma, and those receiving immunosuppressive drugs are at particular risk for oppor­tunistic infections. Candida albicans, herpes simplex, and CMV are the most common pathogens. Candida infection may occur also in patients who have uncontrolled diabetes and those being treated with systemic corticosteroids, radiation therapy, or systemic antibiotic therapy. Herpes simplex can affect normal hosts, in which case the infec­tion is generally self-limited.

Symptoms

Common signs and symptoms of esophagitis include:

  • Difficult swallowing
  • Painful swallowing
  • Chest pain, particularly behind the breastbone, that occurs with eating
  • Swallowed food becoming stuck in the esophagus (food impaction)
  • Heartburn
  • Acid regurgitation

In infants and young children, particularly those too young to explain their discomfort or pain, signs of esophagitis may include:

  • Feeding difficulties
  • Failure to thrive

How is infectious esophagitis diagnosed?

You may see a healthcare provider called a gastroenterologist. This is a doctor who specializes in conditions linked to digestive tract health. They may think you have infectious esophagitis if you have symptoms of esophagitis along with a condition that weakens the immune system. Your healthcare provider will ask about your symptoms and health history and give you a physical exam. You may also have tests, such as:

  • Endoscopy. Your healthcare provider uses a tiny camera on a thin, flexible tube to look inside your esophagus for signs of irritation. They might take swabs and scrapings of any white patches, fluid-filled blisters, or sores in your esophagus. These will be tested to find the cause of the infection. Tissue samples (biopsies) are taken and looked at under a microscope to diagnose the cause of the infection.
  • Blood tests. Your blood may be tested for viruses such as herpes simplex virus (HSV).

Treatment

Candidal Esophagitis

Systemic therapy is required for esophageal candidiasis. An empiric trial of antifungal therapy is often administered without performing diagnostic endoscopy. Initial therapy is generally with fluconazole, 400 mg on day 1, then 200– 400 mg/day orally for 14–21 days. Patients not responding to empiric therapy within 3–5 days should undergo endos­copy with brushings, biopsy, and culture to distinguish resistant fungal infection from other infections (eg, CMV, herpes). Esophageal candidiasis not responding to flucon­azole therapy may be treated with itraconazole suspension (not capsules), 200 mg/day orally, or voriconazole, 200 mg orally twice daily. Refractory infection may be treated intravenously with caspofungin, 50 mg daily.

Cytomegalovirus Esophagitis

In patients with HIV infection, immune restoration with antiretroviral therapy is the most effective means of con­trolling CMV disease. Initial therapy is with ganciclovir, 5 mg/kg intravenously every 12 hours for 3–6 weeks. Neu­tropenia is a frequent dose-limiting side effect. Once reso­lution of symptoms occurs, it may be possible to complete the course of therapy with oral valganciclovir, 900 mg once daily. Patients who either do not respond to or cannot tolerate ganciclovir are treated acutely with foscarnet, 90 mg/kg intravenously every 12 hours for 3–6 weeks. The principal toxicity is acute kidney injury, hypocalcemia, and hypomagnesemia.

Herpetic Esophagitis

Immunocompetent patients may be treated symptomati­cally and generally do not require specific antiviral therapy. Immunosuppressed patients may be treated with oral acy­clovir, 400 mg orally five times daily, or 250 mg/m2 intrave­nously every 8–12 hours, usually for 14–21 days. Oral famciclovir, 500 mg orally three times daily, or valacyclovir, 1 g twice daily, are also effective but more expensive than generic acyclovir. Nonresponders require therapy with fos­carnet, 40 mg/kg intravenously every 8 hours for 21 days.

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