00:00
So now that we've gone through some of those tests, let's
talk about our first case.
00:04
We have a 44-year-old man with HIV who presents to urgent
care complaining of painful swallowing with both liquids and
solids.
00:12
He otherwise feels well. He takes no medications.
00:15
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.
00:24
On exam, vitals are normal, oropharynx and abdominal exam is
unremarkable.
00:29
And his upper endoscopy findings are shown here.
00:33
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.
00:42
In addition, he's a patient with HIV off his antiretroviral
therapy. He has a normal exam otherwise.
00:50
And on endoscopy he has these white raised, kind of thick
looking plaques throughout his esophagus.
00:57
So the most likely diagnosis here is esophageal thrush or
Candida albicans.
01:05
We'll talk a bit more about that next.
01:08
So there are three main types of esophagitis;
the first is an infectious esophagitis, the second is
pill-induced esophagitis, and the third is eosinophilic
esophagitis.
01:19
We'll talk about each three of these in detail.
01:22
So infectious esophagitis can be caused by many organisms.
01:27
One of the most common causes is Candida albicans.
01:30
It can affect both immunocompromised and immunocompetent
patients.
01:34
They tend to have a white raised plaques on their endoscopy.
01:38
And treatment is with an antifungal agent like fluconazole.
01:42
Patients may also have infection with Cytomegalovirus or
CMV. In general, this usually affects immunocompromised
patients.
01:51
They may have large, superficial ulcerations on endoscopy
and they should be treated with ganciclovir or
valganciclovir.
01:59
Lastly, they may also have herpes simplex virus or HSV.
02:04
This can affect both immunocompromised and immunocompetent
patients but tends to mostly affect immunocompromised.
02:11
They may have small, deep ulcerations on their endoscopy
And you treat them with acyclovir.
02:17
Our second type of esophagitis is pill-induced esophagitis.
02:23
This is when pills become stuck in the esophagus and cause
local erosions.
02:28
Patients will present with pain with swallowing, difficulty
swallowing, and may have chest pain.
02:34
Common medications that cause this are basically any pills
that are large and difficult to swallow.
02:41
So some common culprits are; bisphosphonates
like alendronate, antibiotics such as doxycycline, potassium
supplements, and Iron supplements.
02:52
All of these are known to be large pills that commonly cause
esophagitis.
02:57
Over here on the right you can see an upper endoscopy that
shows stellate erosions that are consistent with
pill-induced esophagitis.
03:05
So in general, what you want to do is prevent this from
happening.
03:09
In general, you tell patients to drink plenty of water with
their medications and avoid lying down for 30 mins after
they take their pills.
03:17
Our third type of esophagitis is eosinophilic esophagitis.
03:22
This is a rare condition but it is commonly tested.
03:25
So it is an esophageal squamous mucosal inflammation that
results from eosinophils infiltrating the esophageal tissue.
03:34
Some keywords to note for test-taking purposes are;
young man with atopy who presents with dysphagia and
frequent food impactions.
03:43
It tends to be associated with food allergies, asthma,
eczema, and GERD.
03:50
The diagnosis is made by upper endoscopy.
03:55
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
trachealized esophagus;
when you begin to see rings around the esophagus much like
the appearance of the trachea,
and you may see small white plaques that may look like
candidiasis.
04:18
This patient should be treated with an eight-week trial of
proton pump inhibitor or topical glucocorticoids.
04:26
So now let's return to our case.
04:29
We had a 44-year-old man with HIV off his medications with a
normal exam
but his endoscopy shows these white raised thick plaques
throughout the esophagus.
04:39
So the first step is to make the diagnosis since he's
immunocompromised
and he has pain with swallowing, you should think about
candidiasis.
04:49
And the next step is to treat with oral fluconazole.