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Infectious Esophagitis

Infectious Esophagitis. Immunocompromised Host -Steroids, Chemo/Rad therapy, AIDS, Transplant patients Endoscopic Appearance Location - Often more proximal than reflux. Candidal Esophagitis. Normal Flora, ubiquitous agent

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Infectious Esophagitis

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  1. Infectious Esophagitis • Immunocompromised Host • -Steroids, Chemo/Rad therapy, AIDS, Transplant patients • Endoscopic Appearance • Location • - Often more proximal than reflux

  2. Candidal Esophagitis • Normal Flora, ubiquitous agent • - may gain selective advantage after antibiotics or in immunocompromised • Acute presentation of odynophagia/dysphagia • Endoscopic appearance of white -yellow plaques - “cottage cheese”

  3. Candida

  4. Candidal EsophagitisHistopathology • Clumps of necrotic squamous debris • Neutrophils in surface epithelium • - Sometimes large aggregates of lymphocytes • Pseudohyphae grow perpendicular to axis of superficial squamous cells • PAS or GMS stains help identify organism

  5. Candida

  6. Candida

  7. Candida PAS stain

  8. Candida Lymphocytic reaction

  9. Herpes Esophagitis • Either Herpes Simplex type 1 or 2 • Reactivation in immunocompromised adults • - usually type 1 • Neonates - esophagus involved by disseminated intrapartum infection • - usually type 2

  10. Herpes Esophagitis • Acute presentation of odynophagia/dysphagia, may have GI bleeding • Endoscopic appearance of grouped vesicles, erosions, or ulcers - depending on stage • Located in mid to lower 1/3 of esophagus

  11. Herpes EsophagitisHistopathology • Viral inclusions in squamous epithelium • - Cowdry A and B inclusions • Multinucleated cells with smudgy nuclear inclusions • Aggregates of macrophages in exudate

  12. HSV

  13. HSV

  14. HSV Macrophages often seen under infected epithelium

  15. Macrophages in HSV

  16. HSV Ipox

  17. CMV Esophagitis • Reactivation in immunocompromised hosts • - AIDS and Transplant patients at high risk • Accompanied by systemic infection • - unlike HSV • Clinical presentation identical to HSV • Single distal ulcer most common endoscopic appearance

  18. CMV EsophagitisHistopathology • Nuclear and cytoplasmic inclusions present in endothelial cells, macrophages, smooth muscle / stromal cells - not present in squamous cells • Nuclear inclusion is classically Cowdry type A • Cytoplasm of cell may show granular inclusions, but these form after nuclear inclusions and may not be present in small biopsy specimens

  19. CMV ulcer

  20. CMV and macrophages

  21. CMV

  22. CMV

  23. HIV Associated Esophagitis • Giant esophageal ulcers for which no pathogen can be found • - Deep ulcers in mid or distal esophagus, often greater than 1 cm in diameter • - HIV RNA present by in-situ studies • - Treatment with steroids is helpful, but patients often relapse after steroids are withdrawn

  24. Where to Biopsy? • In Candida, the superficial necrotic debris is most likely to have the diagnostic yeast and pseudohyphae • In HSV, the edge of the ulcer is most likely to harbor inclusions • In CMV, the granulation tissue and muscle from the deepest portion of the ulcer are probably best

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