Learning Radiology xray montage

HIV Esophagitis

General Considerations

  • Most patients with HIV related esophagitis have Candidiasis
  • Other pathogens include cytomegalovirus (CMV), herpes simples virus (HSV) and Mycobacterium-avium intracellulare (MAI)
  • HIV (idiopathic) esophagitis may be the cause if no other pathogens are found

Clinical Findings

  • Dysphasia and odynophagia are common symptoms with advanced HIV
  • Candida and HSV esophagitis occur usually with CD4 counts less than 200 cells/mm3
  • CMV and idiopathic HIV ulcers usually occur with CD4 counts less than 200
  • Acute onset of symptoms is most common
  • Large, flat ulcers >1cm

Imaging Findings

  • Endoscopy with biopsy is the best method of establishing a specific etiology
  • Imaging studies (esophagram) may show giant esophageal ulcers
  • There may be surrounding, smaller satellite lesions
  • May be surrounded by rim of edema

Differential Diagnosis

  • CMV, like HIV esophagitis, can produce giant esophageal ulcers
  • Candida classically produces longitudinally oriented, plaque-like lesions in upper or mid-esophagus
    • Numerous plaques, frequently found in AIDS patients, may produce a “shaggy” appearance to the esophagus
  • Herpes usually produces multiple, small superficial ulcers without plaques, usually in the mid to upper esophagus
  • CMV typically produces large, flat ulcers surrounded by a rim of edema


  • Fluconazole or itraconazole are usually used for Candidal infections
  • Acyclovir or ganciclovir are used with HSV infections
  • HIV ulcerations can be treated with steroids or thalidomide

HIV esophagitis

HIV Esophagitis.
Large ulcers (red, black and white arrows) are seen in these two views of the distal esophagus from an esophagram in a patient with odynophagia and a CD4 count of 30. Biopsies of the ulcers were negative for CMV.
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University of California, SF HIV InSite

Infectious Esophagitis eMedicine  Vossough, A and Levine, M