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Old 09-29-2012
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Arrow Gyrus Daily Questions; Internal Medicine #40

. A 36-year-old female with AIDS and a CD4 count of 35/mm 3 presents with odynophagia and progressive dysphagia. The patient reports daily fevers and a 20-lb weight loss. The patient has been treated with clotrima-zole troches without relief. On physical examination the patient is cachectic with a body mass index (BMI) of 16 and a weight of 86 lb. The patient has a temperature of 38.2°C (100.8°F). She is noted to be orthostatic by blood pressure and pulse. Examination of the oropharynx re-veals no evidence of thrush. The patient undergoes EGD, which reveals serpiginous ulcers in the distal esophagus without vesicles. No yellow plaques are noted. Multiple biopsies are taken that show intranuclear and intracyto-plasmic inclusions in large endothelial cells and fibro-blasts. What is the best treatment for this patient’s esophagitis?


A. Ganciclovir
B. Thalidomide
C. Glucocorticoids
D. Fluconazole
E. Foscarnet
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CMV ? A. Ganciclovir?
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A. Ganciclovir ....????
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A. Ganciclovir for CMV esophagitis.
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The answer is A. Ganciclovir
This patient has symptoms of esophagitis. In patients with HIV various infections can cause this disease, including herpes simplex virus (HSV), cytomegalovirus (CMV), varicella zoster virus (VZV), Candida, and HIV itself.


The lack of thrush does not rule out Candida as a cause of esophagitis, and EGD is necessary for diagnosis.

CMV classically causes serpiginous ulcers in the distal esophagus that may coalesce to form large giant ulcers. Brushings alone are insufficient for diagnosis, and biopsies must be performed. Biopsies reveal intranuclear and intracytoplasmic inclusions with enlarged nuclei in large fibroblasts and endothelial cells. Intravenous ganciclovir is the treatment of choice, and valganciclovir is an oral preparation that has been introduced recently.

Foscarnet is useful in treating ganciclovir-resistant CMV.


Herpes simplex virus manifests as vesicles and punched-out lesions in the esophagus with the characteristic finding on biopsy of ballooning degeneration with ground-glass changes in the nuclei. It can be treated with acyclovir or foscarnet in resistant cases.

Candida esophagitis has the appearance of yellow nodular plaques with surrounding erythema. Treatment usually requires fluconazole therapy.

Finally, HIV alone can cause esophagitis that can be quite resistant to therapy.
On EGD these ulcers appear deep and linear.

Treatment with thalidomide or oral glucocorticoids is employed, and highly active antiretroviral therapy should be considered.
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Gastroenterology-, Infectious-Diseases, Internal-Medicine-, Step-2-Questions

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