darkhorse
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A 43-year-old man with acquired immunodeficiency syndrome (AIDS) is in the hospital for pneumonia. On his second hospital day, he reports difficulty swallowing his meals. He says that for the last month he has had difficulty swallowing food and medications. He also occasionally feels a burning pain in his upper chest when swallowing. He denies abdominal pain, nausea, or vomiting. Vital signs are: 37.0 C (98.6 F), blood pressure 129/88 mm Hg, pulse 80/min. Examination of his mouth reveals pink oral mucosa and a normal tongue. He has no significant cervical lymphadenopathy. Abdominal examination is normal. The patient's last CD4 count was performed 5 months ago and at that time was 190/mm3. The most appropriate next step in the management of this patient is to
A. order esophagogastroduodenoscopy (EGD)
B. order a Helicobacter pylori antibody test
C. prescribe a trial of antacids and schedule a follow-up appointment
D. prescribe oral acyclovir
E. prescribe oral fluconazole
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| Doc750
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E
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| titly
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esophageal candidiasis. E. prescribe oral fluconazole
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| dr penicillin
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first fluconazole trial if no improvement than esophagoscopy
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| darkhorse
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The correct answer is A. The symptoms of dysphagia and odynophagia in a patient with AIDS are highly suspicious for esophagitis. The causes of esophagitis in the setting of AIDS or other immunocompromised states include Candida albicans, cytomegalovirus (CMV), and herpes simplex virus (HSV). The most frequent cause is C. albicans, which accounts for 50-70% of all cases. Esophagogastroduodenoscopy (EGD) is the best way to diagnose the etiology of esophagitis by providing both direct visualization of the esophageal lesions and the ability to obtain biopsies. If the patient has oral thrush and symptoms of esophagitis, the most likely etiology is C. albicans and treatment with fluconazole can be initiated empirically. This patient, however, has normal oral mucosa and needs an EGD prior to treatment.
The Helicobacter pylori antibody test (choice B) is used to determine the etiology of gastric ulcers. This test is not indicated in this patient because he does not have symptoms of ulcer disease. The symptoms of dysphagia and odynophagia in a patient with AIDS are highly suspicious for a fungal or viral esophagitis.
A trial of antacids (choice C) is inappropriate for this patient. The symptoms of dysphagia and odynophagia in a patient with AIDS are highly suspicious for fungal or viral esophagitis. Antacids are used primarily for gastroesophageal reflux disease and will not help in this case. A follow-up appointment is important, however, after the patient has an esophagogastroduodenoscopy (EGD) and is started on appropriate medications.
Treatment with acyclovir (choice D) is premature at this time. There are multiple causes of esophagitis in patients with AIDS and an esophagogastroduodenoscopy (EGD) should be performed to evaluate the esophageal lesions as well as to obtain biopsies. If the esophagitis is caused by herpes simplex virus (HSV), acyclovir is the anti-viral medication of choice.
Treatment with fluconazole (choice E) is premature at this time. There are multiple causes of esophagitis in patients with AIDS and esophagogastroduodenoscopy (EGD) should be performed to evaluate the esophageal lesions as well as to obtain biopsies. If the esophagitis is caused by Candida albicans, fluconazole is the anti-fungal medication of choice.
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| Doc750
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that contradicts the treatment algorithm in UW, FA, and step up.
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| darkhorse
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as suggested in the q answer...if the patient has oral thrush....than u can start empirical fluconazole....but in the q it says the oral mucosa is normal...so we have to prove before we start the therapy...
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| doyoudig
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agree w/ darkhorse and UW does say that w/ presence of Oral Thrush in an HIV Pt start Rx right away and see if it works, if it did not than go for EGD
But in this case u don't know enough to point to Candida even though it is the MCC of esoph in HIV Pts so do EGD + Biopsy to confrim Dx
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