Let’s take a look at
We’ll begin by looking at viruses.
The usual suspects: CMV,
Herpes, Varicella, HIV.
In the esophagus, look for
an immunocompromised patient.
Fungal: Candida being the most prevalent
here, immunocompromised patient.
Bacterial: something like a Beta-hemolytic
streptococci such as Pyogenes.
CMV Esophagitis will be
our first discussion.
Immunocompromised patient is, or immunocompromised
host, is the patient that you’re dealing with.
Reactivation of latent infection.
Remember with viruses, if the patient becomes
immunocompromised, there’ll be reactivation of it.
Concurrent disease in the
retina, liver and lungs.
Whenever you have these viral infections, or infections in
general, and if esophagus is involved and you know your patient
is immunocompromised, very likely there would be other organs
involved including, you’ve heard of retinopathy with CMV.
Or retinitis, liver, lungs involved.
Endoscopy is the test of choice, serology for
CMV not helpful, CMV PCR may be positive.
Polymerase chain reaction might be positive so
that you can identify your patient with CMV.
Whenever there is infectious esophagitis, now apart from maybe
dysphagia, there’s going to be painful swallowing - odynophagia.
Sub-sternal chest pain and a viral
infection, a low grade type of fever.
Endoscopy, you want to pay
attention to description here.
It’s a well circumscribed ulcer
with normal mucosa surrounding it.
What we’ll do here, so that you know as to what to expect
and what to compare this to, would be HSV esophagitis.
So Cytomegalovirus esophagitis, you’d find this ulcer
to be circumscribed and rather larger when compared
to upon endoscopy, a HSV or Herpes type of esophagitis,
where there you’d find crops of vesicles.
The biopsy shows viral inclusions, has
been more specific for CMV immunostains.
The viral tissue culture, not sensitive and
Foscarnet may be necessary for resistance.
Acyclovir, Gancyclovir, Foscarnet - drugs that
you want to keep in mind in the family of Herpes.
Management, it would in fact be your IV ganciclovir
followed by something like Valgancyclovir
and Foscarnet if you’re thinking about your
refractive cases that we just mentioned.
On endoscopic examination of CMV, remember that
your patient most likely immunocompromised.
Maybe taking drugs or maybe perhaps
even, you’re thinking about HIV status.
You’ll notice here, couple things
that I wish to point out to you.
We’ve looked at a bunch of upper
endoscopic pictures, we’ve looked at rings,
looked at strictures, we looked at cancers
of esophagus, we looked at Barrett’s.
Here, you’ll notice the following.
Here we have a focal region of ulceration taking place
with the surrounding area which is relatively normal.
I want you to focus on normal.
There’s no narrowing of the lumen, the caliber
of the esophageal lumen has not been compromised.
I do want you to pay attention to the blood vessels
that are passing in the lining of the esophagus.
This is all perfectly normal.
At some point of time, you will be responsible to identify
esophageal varices secondary to portal hypertension.
And you’ll notice at that point, that the bulging of the
esophagus will be taking place as you would expect with varices.
Here, none of this is present and I need
you to get more and more comfortable
with upper endoscopy so that you’re able
to identify, lesions just like that.
This is CMV esophagitis.