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so now that we've gone through some of
those tests let's talk about our first
case we have a 44 year old man with HIV
who presents to Urgent Care complaining
of painful swallowing with both liquids
and solids he otherwise feels well he
takes no medications he stopped taking
his antiretroviral medications two years
ago after he moved to a new city and has
not yet established with a new primary
care doctor on exam vitals are normal or
pharynx and abdominal exam is
unremarkable and his upper endoscopy
findings are shown here so what is the
best next step in management so let's
identify some key features in this case
he has odynophagia
or pain with swallowing in addition he's
a patient with HIV office antiretroviral
therapy he has a normal exam otherwise
and an endoscopy he has these white
raised kind of thick looking plaques
throughout his esophagus so the most
likely diagnosis here is esophageal
thrush or Candida albicans we'll talk a
bit more about that next so there are
three main types of esophagitis the
first is this infectious esophagitis the
second is pill induced esophagitis and
the third is a extent of filler
esophagitis we'll talk about each three
of these in detail so infectious
esophagitis can be caused by many
organisms one of the most common causes
is Candida albicans it can affect both
immunocompromised and immunocompetent
patients they tend to have a white
raised plaques on their endoscopy and
treatment is with an antifungal agent
like fluconazole patients may also have
infection with cytomegalovirus or CMV in
general this usually affects
immunocompromised patients they may have
small deep ulcerations on their
endoscopy and they should be treated
with gancyclovir or val ganciclovir
Lessie they may also have herpes simplex
virus or HSV this can affect both
immunocompromised and immunocompetent
patients but tends to mostly affected me
compromised they may have large
superficial ulcerations on endoscopy and
you treat them with acyclovir our second
type of esophagitis is pill induced
esophagitis this is when pills become
stuck in the esophagus and cause local
erosions patients will present with pain
with swallowing difficulty swallowing
and may have chest pain common
medications that cause this are
basically any pills that are large and
difficult to swallow so some common
culprits are bisphosphonates like
alendronate antibiotics such as
doxycycline potassium supplements and
iron supplements all of these are known
to be large pills that commonly cause
esophagitis over here on the right you
can see an upper endoscopy that shows
still 8 erosions that are consistent
with pill induced esophagitis so in
general what you want to do is prevent
this from happening in general you tell
patients to it drink plenty of water
with their medications and avoid lying
down for 30 minutes after they take
their pills our third type of
esophagitis is a asana philic
esophagitis this is a rare condition but
it is commonly tested so it is an
esophageal squamous mucosal inflammation
that results from a asana fills
infiltrating the esophageal tissue some
key words to note for testing purposes
are young man with ATP who presents with
dysphasia and frequent food impactions
it tends to be associated with food
allergies asthma eczema and GERD the
diagnosis is made by upper endoscopy
and the typical features you may see are
these longitudinal furrows along the
length of the esophagus some fragile
mucosa
you may see what's called a trachea
lized esophagus when you begin to see
rings around this abacus much like the
appearance of the trachea and you may
see small white plaques that may look
like candidiasis these patients should
be treated with an eight-week trial of a
proton pump inhibitor or topical
glucocorticoids so now let's return to
our case we had a 44 year old man with
HIV off his medications with a normal
exam but his endoscopy shows he's white
raised thick plaques throughout the
esophagus so the first step is to make
the diagnosis since he's
immunocompromised and he has pain with
swallowing you should think about
candidiasis and the next step is to
treat with oral fluconazole
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you