Wilcox C M, Karowe M W
Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303.
Gastroenterologist. 1994 Sep;2(3):188-206.
With the advent of transplantation and the acquired immunodeficiency syndrome (AIDS), esophageal infections are now a common medical problem. The most common infections involving immunocompromised nonhuman immunodeficiency virus (HIV)-infected patients include viral disease (herpes simplex virus and cytomegalovirus) and Candida. In HIV-infected patients, Candida esophagitis is by far the most common infection; viral disease is seen less frequently. In contrast to other immunocompromised patients, these patients may have esophageal disease from a variety of other fungi and viruses. Immunocompromised patients in whom esophageal symptoms develop after transplantation usually undergo endoscopy for diagnosis because of the possibility that alterations in immunosuppressive agents will be required if an opportunistic infection is causative. In contrast, HIV-infected patients with new-onset esophageal symptoms are usually treated empirically with oral systemic antifungal therapy given the prevalence of Candida esophagitis. Barium esophagography may, however, be worthwhile, depending on the clinical setting, such as the possibility of a reflux-induced stricture. In HIV-infected patients, radiography is less often utilized in the setting of a low CD4 lymphocyte count given the likelihood of an opportunistic infection that requires endoscopic biopsy for a definitive diagnosis. Oral systemic antifungal therapy with either ketoconazole or fluconazole is very effective for the treatment of Candida esophagitis, and these agents have also shown efficacy in the prophylaxis of fungal infections following transplantation, as well as in patients with AIDS following oropharyngeal and esophageal candidiasis. Antiviral therapy with acyclovir for herpes simplex virus and ganciclovir and foscarnet for cytomegalovirus are effective. The efficacy rate for these antiviral agents appears similar in all immunocompromised patients. These agents have also been utilized prophylactically following transplantation. In summary, a variety of infections may involve the esophagus in immunocompromised patients. The diagnostic strategies utilized in these patients are similar; endoscopy and biopsy are the most cost-effective strategy given the need for mucosal biopsy for a definitive diagnosis. Importantly, efficacious therapy is available to treat these disorders. Nevertheless, in patients with AIDS, identification of an opportunistic esophageal disease portends a poor prognosis.
随着移植技术的出现以及获得性免疫缺陷综合征（艾滋病）的出现，食管感染如今已成为一个常见的医学问题。涉及免疫功能低下但未感染人类免疫缺陷病毒（HIV）患者的最常见感染包括病毒性疾病（单纯疱疹病毒和巨细胞病毒）以及念珠菌感染。在感染HIV的患者中，念珠菌食管炎是迄今为止最常见的感染；病毒性疾病则较少见。与其他免疫功能低下的患者不同，这些患者可能因多种其他真菌和病毒而患上食管疾病。移植后出现食管症状的免疫功能低下患者通常会接受内镜检查以进行诊断，因为如果是机会性感染导致的，可能需要调整免疫抑制剂。相比之下，鉴于念珠菌食管炎的患病率，出现新发食管症状的HIV感染患者通常会接受口服全身性抗真菌治疗。然而，根据临床情况，如存在反流性狭窄的可能性，食管钡餐造影可能是有价值的。在CD4淋巴细胞计数较低的HIV感染患者中，鉴于可能存在需要内镜活检才能确诊的机会性感染，放射检查较少使用。口服酮康唑或氟康唑进行全身性抗真菌治疗对念珠菌食管炎的治疗非常有效，这些药物在预防移植后真菌感染以及艾滋病患者口腔和食管念珠菌病方面也显示出疗效。使用阿昔洛韦治疗单纯疱疹病毒感染、更昔洛韦和膦甲酸钠治疗巨细胞病毒感染的抗病毒治疗是有效的。这些抗病毒药物在所有免疫功能低下患者中的有效率似乎相似。这些药物在移植后也被用于预防性治疗。总之，免疫功能低下患者的食管可能会受到多种感染。这些患者所采用的诊断策略相似；鉴于明确诊断需要进行黏膜活检，内镜检查和活检是最具成本效益的策略。重要的是，有有效的治疗方法来治疗这些疾病。然而，在艾滋病患者中，发现机会性食管疾病预示着预后不良。
