Question
A 30-year-old man with a recent diagnosis of human immunodeficiency virus (HIV) infection presents with painful swallowing (odynophagia). Despite starting a proton pump inhibitor, upper gastrointestinal (GI) endoscopy reveals serpiginous (snake-like) ulcers with normal-appearing surrounding mucosa in the distal esophagus. What is the most likely diagnosis?
| A. |
Herpes simplex esophagitis |
| B. |
Gastroesophageal reflux disease |
| C. |
Cytomegalovirus esophagitis |
| D. |
Candida esophagitis |
|
Correct Answer » C Explanation |
 |
Clinical Reasoning for the Correct Answer:
– Serpiginous ulcers in the distal esophagus are highly characteristic of CMV esophagitis in immunocompromised patients.
– CMV esophagitis presents with large, linear, or serpiginous ulcers and usually occurs in the distal esophagus.
– The patient’s history of HIV and odynophagia, combined with the endoscopic appearance, points to CMV rather than other causes.
Why Option A is Incorrect (Herpes simplex virus esophagitis):
– HSV esophagitis presents with multiple, small, well-circumscribed “volcano-like” ulcers, often in the mid-to-proximal esophagus.
– Typically, ulcers are not serpiginous or large; base is often “punched-out.”
– HSV ulcers are often surrounded by normal mucosa but are not described as linear/serpiginous.
Why Option B is Incorrect (GERD):
– GERD may cause erosive esophagitis, strictures, or Barrett’s esophagus, but not large, serpiginous ulcers.
– GERD-related ulcers usually occur with surrounding inflamed mucosa, not isolated “serpiginous” ulcers in healthy tissue.
– GERD is less likely in an immunocompromised young man with acute odynophagia and classic endoscopic findings.
Why Option D is Incorrect (Candida esophagitis):
– Candida esophagitis produces white plaques (pseudomembranes) throughout the esophagus, not isolated ulcers.
– If ulcers are present, they are typically shallow and associated with underlying plaques.
– Classic appearance is diffuse and not restricted to large, linear, or serpiginous ulcers.