Idiopathic esophageal ulcer associated with HIV: a forgotten entity in patients with acquired immunodeficiency syndrome

Abstract

Esophageal ulceration in patients with stage 3 HIV infection may have infectious, inflammatory, neoplastic, chemical, or irritative etiologies, and their behavior has  changed with the advent of highly active antiretroviral therapy. We report the case of a 33-year-old patient with a recent diagnosis of stage 3 HIV who presented with  oral ulcers, progressive dysphagia, and febrile syndrome. An extensive diagnostic workup ruled out opportunistic infections, and upper gastrointestinal endoscopy revealed an ulcer involving 60% of the circumference of the mid-esophagus. Microbiological, molecular, and histopathological studies excluded the most common etiologies. After 14 days of ganciclovir therapy without clinical improvement and a repeat endoscopy again negative for cytomegalovirus, a diagnosis of HIV-associated idiopathic esophageal ulcer was established, and antiretroviral therapy along with systemic corticosteroids was initiated. Two months later, near-complete healing was observed; however, gastric lesions suggestive of unmasking Kaposi’s sarcoma-associated immune reconstitution inflammatory syndrome, a clinically relevant finding given that corticosteroids increase mortality in this setting. This case highlights the diagnostic challenge posed by this entity and, additionally, raises discussion about the need to explore therapeutic approaches that minimize the risks associated with corticosteroid use, given the limited evidence currently available.