A 50 year‐old woman with chronic hidradenitis suppurativa presented with three weeks of progressive difficulty swallowing. She initially had dysphagia only for solid foods, but it has now progressed to liquids as well. She also reported odynophagia, nausea immediately after eating, and reports that she has lost ten pounds. Her physical exam was only notable for extensive non‐draining hidradenitis lesions across lower abdomen and similar lesions on her buttocks with sinus tracts and serosanguinous drainage. Oropharyngeal exam was normal without erythema, exudates or vesicles. Laboratory evaluation revealed prerenal azotemia, iron deficiency anemia, leukocytosis and thrombocytosis. An esophagram revealed esophageal dysmotility, but no evidence of stricture. Upper endoscopy revealed severe esophagitis, and biopsies found evidence of herpes and candida. An extensive immune workup was performed including HIV antibody testing, lymphocyte enumeration panel, immunoglobulin levels and cancer screening, but was negative. She was treated with acyclovir and fluconazole with marked improvement in her symptoms and was discharged home, able to eat without difficulty.
Swallowing difficulty is a common complaint encountered by a hospitalist. It is important to be able to elicit the history necessary to distinguish between dysphagia and odynophagia, so that one can find the correct cause and start appropriate treatment. Patients with dysphagia have difficulty swallowing; they either have oropharyngeal problems where the problem is with initiating the swallow, or esophageal problems where food will mechanically or functionally get “stuck”. Patients with esophagitis will describe odynophagia, or pain with swallowing, however they may report esophageal dysphagia as well.
Esophagitis is most commonly caused by noninfectious causes, like gastroesophageal reflux, pill‐induced esophagitis or eosinophilic esophagitis. While infectious esophagitis is most commonly described in the immunocompromised, it can also been seen in immunocompetent patients. Patients with herpes esophagitis often present with acute odynophagia, heartburn, and fever. They may or may not have a systemic prodrome or the hallmark vesicular labial or genital lesions. Endoscopic exam reveals a friable mucosa, numerous ulcers and whitish exudates and biopsies show characteristic cytopathic effect, although immunochemistry is the preferred test.
Esophageal candidiasis, while also predominantly seen in the immunocompromised, can rarely be found in the immunocompetent in the right clinical setting. One study describes carcinoma, diabetes, acid suppression, steroid use and previous gastric surgery as predisposing factors, although almost half of the patients lack any of these factors. Our patient had been on multiple courses of antibiotics, which most likely made her more prone to candida colonization.
A thorough history and physical examination, including history of medications can aid hospitalists in properly evaluating a dysphagia or odynophagia complaint. Esophagogastroduodenoscopy is the essential for making the proper diagnosis for a patient with esophageal dysphagia or odynophagia without pharyngeal lesions. Although infectious esophagitis is uncommonly seen in immunocompetent patients, both herpes simplex virus and candida can cause esophagitis in individuals without immune deficiencies.