Helicobacter pylori - Portal Neonatal

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Infectious esophagitis
Table 3.1 Causes of esophageal disease in HIV infection and AIDS
Common Uncommon Rare
Candida Herpes simplex virus Neoplasm
Cytomegalovirus Gastroesophageal reflux disease Mycobacteria
Idiopathic Protozoa
present in the normal oral flora, where their
growth is controlled by commensal organisms.
Conditions predisposing to esophageal candidiasis
in immunocompetent subjects are inhaled or
ingested corticosteroids, prolonged antibiotic
administration, acid suppressive therapy, disorders
of esophageal motility, malnutrition, diabetes
mellitus and neck or head radiotherapy because of
malignancy. All abnormalities in cellular immunity
lead to esophageal candidiasis, whereas
improved management of immunosuppressive
therapies and antifungal prophylaxis have
reduced the occurrence of esophageal candidiasis
in solid-organ transplant recipients. 7
Esophageal candidiasis has the classical appearance
of white or yellow plaques coating the
esophageal mucosa (Figure 3.1). These plaques can
extend up to the proximal esophagus, are usually
thick and, characteristically, cannot be washed or
brushed off, unlike food or milk residues overlying
esophageal mucosa. They include desquamated
esophageal epithelial cells intermingled with
inflammatory cells, bacteria and mycelia and
spores typical for Candida. 8 The underlying squamous
esophageal epithelium usually appears
uninvolved, and ulcerations occur rarely.
Typical symptoms of esophageal candidiasis are
painful swallowing (odynophagia) or dysphagia
(difficulty in swallowing, described as food ‘sticking’)
(Table 3.2). 3,9 Any patient with risk factors for
esophageal infection and complaining of dysphagia
should be suspected for esophageal
candidiasis. The latter, however, can be detected
by chance in asymptomatic subjects. When evaluating
patients with esophageal complaints, an
important part of the physical examination is a
close inspection of the oropharynx. However, oral
candidiasis is not predictive of esophageal involvement
and the latter can occur in the absence of oral
candidiasis even in the immunocompromised
Figure 3.1 Esophageal candidiasis. White plaques
coating the lower third of the esophageal mucosa.
subject. Complications from esophageal candidiasis
occur rarely. Hematemesis suggests underlying
ulcerative esophagitis that occurs if the disease is
severe and there is an associated coagulopathy.
Given that esophageal candidiasis is the most
common of opportunistic infections of the esophagus
in subjects with a predisposing condition (e.g.
HIV infection, transplantation, immunosuppressive
therapy), an empirical antifungal therapy has been
proposed, with further diagnostic evaluation based
on the clinical response (Figure 3.2). Interestingly, a
prospective study comparing empirical fluconazole
to endoscopy in HIV-infected adults has shown
empirical fluconazole to be the best initial management
strategy. 3 Candida esophagitis usually
responds rapidly to fluconazole. 10
Before the advent of upper endoscopy, a barium
esophagram was used as the initial diagnostic tool.
However, a number of studies have shown the rela-