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  #1  
Old 05-19-2013
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Default gastroenterology q2

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. She has been treated with clotrimazole troches with-out relief. On physical examination the patient is cachectic with a body mass index (BMI) of 16 and a weight of 86 lb.
She has a temperature of 38.2°C (100.8°F) and is noted to be orthostatic by blood pressure and pulse. Examination of the oropharynx reveals no evidence of thrush. The patient undergoes esophagogastroduodenoscopy (EGD), which reveals serpiginous ulcers in the distal esophagus without vesicles. No yellow plaques are noted. Multiple biopsies are taken that show intranuclear and intracytoplasmic inclu-sions in large endothelial cells and fibroblasts. What is the best treatment for this patient’s esophagitis?


A. Ganciclovir
B. Glucocorticoids
C. Fluconazole
D. Foscarnet
E. Thalidomide
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Old 05-19-2013
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Quote:
Originally Posted by cingulate.gyrus View Post
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. She has been treated with clotrimazole troches with-out relief. On physical examination the patient is cachectic with a body mass index (BMI) of 16 and a weight of 86 lb.
She has a temperature of 38.2°C (100.8°F) and is noted to be orthostatic by blood pressure and pulse. Examination of the oropharynx reveals no evidence of thrush. The patient undergoes esophagogastroduodenoscopy (EGD), which reveals serpiginous ulcers in the distal esophagus without vesicles. No yellow plaques are noted. Multiple biopsies are taken that show intranuclear and intracytoplasmic inclu-sions in large endothelial cells and fibroblasts. What is the best treatment for this patient’s esophagitis?


A. Ganciclovir
B. Glucocorticoids
C. Fluconazole
D. Foscarnet
E. Thalidomide
Looks like CMV esophagitis (clue is CD4 less than 50 and the ulcer characteristics)
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Old 05-19-2013
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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 esolesce to form 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. Given her notable swallowing symptoms, IV ganciclovir is the treatment of choice. Valganciclovir is an effective oral preparation.
Foscarnet is useful in treating ganciclovir-resistant CMV. Herpes simplex virus mani-fests 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 appear-ance 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.hagus that may coa


Last edited by cingulate.gyrus; 05-19-2013 at 10:30 AM. Reason: add
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we must also take into account that this patient probably has electrolyte disturbances.. in which case Foscarnet would be contraindicated because it causes Mg++, Ca++ and K+ changes
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Old 05-19-2013
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Originally Posted by XpaezX View Post
we must also take into account that this patient probably has electrolyte disturbances.. in which case Foscarnet would be contraindicated because it causes Mg++, Ca++ and K+ changes
Thants a good point to add...Thanks XpaezX
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