This patient's history of oral thrush suggests that he is immunocompromised. The endoscopic and histopathological description provided is most consistent with HSV-1.
The most common causes of esophagitis in the immunocompromised (especially in HIV patients) are Candida, HSV-1, and CMV. Of these three infections, only HSV causes eosinophilic intranuclear inclusions (Cowdry Type A inclusions) and multinuclear squamous cells. It is not possible to clinically distinguish between the three infectious causes of esophagitis. Endoscopy and biopsy reveal distinct findings depending on the infectious agent.
Ginaldi et al. state that although HSV esophagitis is most common in the immunocompromised, it can also occur in healthy individuals, with major symptoms being odynophagia and dysphagia. An esophagogram may reveal esophageal ulcers and motor abnormalities may be present. The esophagogram may reveal ulcers in the distal esophagus as well as motor disturbances.
Sutton et al. review other less common causes of esophagitis including TB, aspergillus, histoplasmosis, and blastomycosis as well as their pathogenesis, pathology, clinical manifestations, and epidemiology.
Figure A shows an HIV positive male with a white exudate suggestive of oral thrush.
Figure B shows the punched out lesions of herpetic esophagitis.
Illustration A shows the eosinophilic intranuclear inclusions (Cowdry Type A).
Answer 1: Esophageal carcinoma presents with progressive dysphagia, and squamous cell carcinoma may demonstrate squamous cells on biopsy. However, carcinoma is not consistent with eosinophilic intranuclear inclusions.
Answer 2: Candida is the fungus responsible for oral thrush and can cause esophagitis, but does not explain the eosinophilic intranuclear inclusions seen on biopsy. Candida esophagitis presents with gray-white pseudomembranes on erythematous mucosa on endoscopy, and yeast cells and pseudohyphae on biopsy.
Answer 3: CMV is a common cause of esophagitis in HIV patients. CMV presents with linear ulcerations on endoscopy and both intranuclear and cytoplasmic inclusions on biopsy.
Answer 5: Cryptosporidium classically causes diarrhea in immunocompromised patients
Ginaldi S, Burgert W Jr, Paulk HT Jr. Herpes esophagitis in immunocompetent patients. Am Fam Physician. 1987 Jul;36(1):160-4.
PMID:3604850 (Link to Abstract)
Sutton FM, Graham DY, Goodgame RW. Infectious esophagitis. Gastrointest Endosc Clin N Am. 1994 Oct;4(4):713-29. Review.
PMID:7812643 (Link to Abstract)
USMLE World Step 1 QBank Question #283. Copyright © USMLEWorld, LLC 2012