In a prospective study of 154
AIDS patients, 48 (31%) complained of
pain on swallowing both liquids and solids and 32 (21%) of these also had
dysphagia. While
candidiasis was the most common cause of symptoms (26 patients), discrete ulceration of the oesophagus occurred in 12 instances in 10 patients (four cytomegalovirus, four herpes simplex virus, three
aphthous ulcer, one
peptic ulcer). One patient had a diffuse oesophagitis caused by Mycobacterium avium intracellulare. No cause was found for the oesophageal symptoms in four patients.
Kaposi's sarcoma (KS) was found in seven patients associated with other pathology in four. All 26 patients with oesophageal
candidiasis only, also had oral involvement. All the patients with herpes simplex virus (four) and
aphthous ulcers (three) had obvious perioral involvement. Three of the four patients with cytomegalovirus ulceration had evidence of disease elsewhere (colon or retina). All patients with
Kaposi's sarcoma lesions had skin and buccal cavity involvement. The cause of oesophageal disease was usually obvious at endoscopy. The appearance of
candidiasis was typical and the various ulcerating lesions also had different macroscopic configurations.
Cytomegalovirus infection produced deep linear
ulcers in the distal oesophagus,
herpes simplex oesophagitis is similar in appearance to the typical perioral lesions of fluid filled vesicles. Diagnostic radiology was not helpful in most patients. In nine of 17 patients with
candidiasis, the
barium swallow examination performed within 24 hours of presentation was normal. In only three of seven patients with oesophageal ulceration (three cytomegalovirus, two herpes simplex virus, one aphthous, one peptic) was there evidence of an abnormality. Treatment produces symptomatic relief. All patients with
candidiasis responded to
ketoconazole, the four with herpes simplex virus to
acyclovir and one of three with aphthous ulceration had a dramatic response to
thalidomide. The three patients with
cytomegalovirus infection who were treated with
foscarnet had a prolonged remission of symptoms. The overall prognosis of patients with oesophageal symptoms is poor, with an average survival time from a definitive diagnosis of five months (range one to 13).