A 27-year-old man with HIV comes to the clinic with symptoms of pain every time he swallows (odynophagia) He is not on any antiretroviral therapy and otherwise feels well. Examination of the mouth and pharynx are normal. Which of the following is the most likely diagnosis?
## **Core Concept**
The patient's symptoms of odynophagia (painful swallowing) in the context of HIV infection and the absence of antiretroviral therapy suggest an opportunistic infection or condition related to immunosuppression. The normal examination of the mouth and pharynx does not rule out esophageal involvement.
## **Why the Correct Answer is Right**
The correct answer, **Esophageal candidiasis**, is a common cause of odynophagia in HIV-infected patients, especially those with low CD4 counts or not on antiretroviral therapy. Candida esophagitis results from the overgrowth of Candida species in the esophagus, facilitated by the patient's immunocompromised state. This condition leads to inflammation and ulceration of the esophageal mucosa, causing painful swallowing.
## **Why Each Wrong Option is Incorrect**
- **Option A: Gastroesophageal reflux disease (GERD)**: While GERD can cause dysphagia and sometimes odynophagia, it is less directly related to the patient's HIV status and immunosuppression. GERD symptoms are also often accompanied by heartburn, which is not mentioned.
- **Option B: Cytomegalovirus (CMV) esophagitis**: CMV esophagitis is another opportunistic infection in immunocompromised patients but tends to cause more systemic symptoms and often accompanies other CMV infections. It typically presents with larger ulcers.
- **Option D: Herpes simplex esophagitis**: Herpes simplex virus can cause esophagitis, especially in immunocompromised patients, leading to painful swallowing. However, it usually presents with characteristic vesicular or ulcerative lesions.
## **Clinical Pearl / High-Yield Fact**
A key clinical pearl is that in HIV-infected patients with odynophagia, especially those not on antiretroviral therapy, **esophageal candidiasis** is a leading cause and often presents without oral thrush. Endoscopy with biopsy is diagnostic, showing white plaques and inflammation.
## **Correct Answer:** C. Esophageal candidiasis.