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34 yr old HIV male came with complaints of chest pain burning in nature retrosternal. He is taking HRRT since last 1 yr. CD4 count is 40, viral load 300,000. Loss of weight +ve, history of pain while swallowing food, oropharynx examination normal. What is the next step of management?
a. esophagoscopy, biopsy, cytology
b. oral flucanozole.
c. IV acyclovir
d. IV gancyclovir
e. sublingual nitrate
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Ans is B. Flucanozole
Management of esophagitis in HIV pt is always as follows:
First treat with Flucanozole always considering it as Candidial Inf.
IF no response in 3-5 days...do Esophagoscopy and biopsy
to D/D HSV and CMV
HSV has Volcano like small multiple deep ulcers ...Rx is Acyclovir
while CMV has inclusion bodies and superficial shallow ulcers...Rx is Gan cyclovir..
reference........UW Q bank...IM section ..2007
Thats it for today..c u friends tomorrow
thanks
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the treatment strategy abhijeet gave is correct. n its followed if the pt presents wth dysphagia. but when it is odynophagia, u can exclude candida n suspect CMV. but i donno if the answer is a or d
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in hiv pts if its just plain dyphagia give fluconazole as first step of mx
if there is odynophagia.. do a esophagoscopy as first step of mx
could someone please confirm this?
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when cd4 count is less than 50 then--cmv,mycobacterium avium complex are most commonly involved,thats why i chose gancyclovir.
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depending on cd4 count,its goin to be CMV (CD4<100) rather than candida r HSV(CD4<200) so i go fr CMV n answer is gancyclovir
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Agree w/ abhijeetnakave
As Far as I am aware according to Kaplan if you know the Pt has HIV & Presents w/ Odynopahia --Look for a Oral Truch which culd be clues to the Orgs
1. Give him a Trial of Oral Fluconazole since Candidia is the Most Common cause of Esophagitis Overall and exclusively seen in HIV Pts (HSV and CMV are less comonly seen) and if the Sx's Subside Great, but if not then go for Endoscopy w/ Biopsy next to Find Other Etiology such as HSV, CMV
Cd4 Count, yes its true that < 200 for Candidia, but that's not reliable enough b/c at times it can even be < 100 for Candida as well
So I would go with what is more Common than just relyiing on CD4 count, also Real Exam seems to ask More Common Problems
