Infectious Esophagitis: Causes, Pathophysiology, Clinical Features, Imaging, and Management

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Introduction

Infectious esophagitis is an inflammatory condition of the esophagus caused by opportunistic pathogens such as fungi, viruses, or bacteria. While relatively uncommon in immunocompetent individuals, its prevalence has increased significantly with the rising number of patients who are immunocompromised due to HIV/AIDS, organ transplantation, chemotherapy, corticosteroid therapy, or advanced malignancies.

This comprehensive column explores the cause, etiology, pathophysiology, epidemiology, clinical presentation, imaging features, treatment, and prognosis of infectious esophagitis, with a detailed focus on Candida, Herpes simplex virus (HSV), Cytomegalovirus (CMV), and Mycobacterium tuberculosis-related esophagitis. Illustrations from radiographic and endoscopic studies are included to highlight the diagnostic hallmarks of each entity.

Etiology and Causes

The principal causes of infectious esophagitis include:

  1. Fungal infection – Most commonly Candida albicans, though C. tropicalis, C. krusei, and other non-albicans species are also implicated.

  2. Viral infection – Mainly Herpes simplex virus (HSV-1) and Cytomegalovirus (CMV), particularly in immunosuppressed individuals.

  3. Bacterial infection – Rare, but includes tuberculous esophagitis caused by Mycobacterium tuberculosis.

  4. Predisposing conditions – HIV/AIDS, organ transplantation, diabetes mellitus, long-term steroid use, and chemotherapy.

Pathophysiology

  • Candida esophagitis: Overgrowth of commensal yeast leads to invasion of esophageal mucosa, causing inflammation and plaque formation. Severe cases result in pseudomembrane development and strictures.

  • Herpes esophagitis: HSV infects squamous epithelial cells, producing multinucleated giant cells and shallow ulcers. Viral replication results in mucosal necrosis.

  • CMV esophagitis: CMV primarily infects vascular endothelial cells, producing large, linear, deep ulcers.

  • Tuberculous esophagitis: Rarely primary, usually secondary to pulmonary TB or mediastinal lymph node involvement, with caseating granulomatous inflammation extending into the esophagus.

Epidemiology

  • Candida esophagitis is the most common form, representing nearly 70% of infectious esophagitis cases, particularly in AIDS patients with CD4 counts <200 cells/μL.

  • HSV esophagitis is the second most common, with prevalence up to 5–10% in immunocompromised populations.

  • CMV esophagitis occurs in 2–6% of AIDS patients, particularly those with advanced disease.

  • Tuberculous esophagitis is exceedingly rare (<0.5% of TB cases) but should be suspected in endemic areas.

Clinical Presentation

Patients with infectious esophagitis typically present with:

  • Odynophagia (painful swallowing)

  • Dysphagia (difficulty swallowing)

  • Retrosternal chest pain

  • Fever, malaise, weight loss (especially in viral or TB-associated cases)

  • Oral thrush in Candida esophagitis

  • Hematemesis or upper GI bleeding in severe HSV/CMV cases

Imaging Features

Candida Esophagitis

  • Barium esophagography: Longitudinal plaque-like lesions, irregular mucosal defects, nodular/granular surface.

  • Advanced cases: Shaggy esophageal contour due to pseudomembrane formation.

[Figure 1] Longitudinal plaque-like lesions in Candida esophagitis.

[Figure 2] Granular mucosal changes due to edema and inflammation.

Herpes Esophagitis

  • Findings: Multiple small, superficial “punched-out” ulcers, typically in the mid-esophagus.

  • It may appear linear, ring-like, or stellate with a radiolucent halo.

[Figure 3] Multiple discrete ulcers in HSV esophagitis.

CMV Esophagitis

  • Findings: Large, deep, linear ulcers, often with irregular borders.

  • Indistinguishable from HSV in advanced cases.

[Figure 4] CMV esophagitis in an AIDS patient with giant linear ulcerations.

Tuberculous Esophagitis

  • Findings: Strictures, irregular ulcerations, fistulas, or extrinsic compression by mediastinal TB nodes.

  • May resemble corrosive or radiation-induced strictures.

[Figure 5] Mid-esophageal ulcer and stricture in tuberculous esophagitis.

Treatment

  1. Candida Esophagitis

    • First-line: Fluconazole (oral/IV)

    • Alternatives: Itraconazole, voriconazole, echinocandins in resistant cases

  2. Herpes Esophagitis

    • Antivirals: Acyclovir, valacyclovir, or famciclovir

    • Supportive care: hydration, analgesia

  3. CMV Esophagitis

    • Antivirals: Ganciclovir (IV), valganciclovir (oral)

    • Severe/refractory cases: foscarnet or cidofovir

  4. Tuberculous Esophagitis

    • Standard anti-TB regimen (isoniazid, rifampin, pyrazinamide, ethambutol) for 6–9 months

    • Surgical intervention in case of fistula or severe stricture

Prognosis

  • Candida: Good prognosis with antifungal therapy; relapse possible if underlying immunosuppression persists.

  • HSV & CMV: Generally good with antiviral treatment, but prognosis depends on immune status.

  • Tuberculous esophagitis: High morbidity if untreated; curable with appropriate anti-TB therapy.

Quiz

1. What is the most common cause of infectious esophagitis?

(A) HSV

(B) CMV

(C) Candida

(D) Tuberculosis

2. Which imaging finding is most characteristic of Candida esophagitis?

(A) Large linear ulcers

(B) Longitudinal plaque-like lesions

(C) Mid-esophageal strictures

(D) Punched-out ulcers

3. In which patient group is CMV esophagitis most frequently observed?

(A) Healthy adults

(B) AIDS patients

(C) Diabetic patients

(D) Pediatric population

4. What is the first-line treatment for HSV esophagitis?

(A) Fluconazole

(B) Acyclovir

(C) Ganciclovir

(D) Rifampin

5. Which complication is most likely in tuberculous esophagitis?

(A) Oral thrush

(B) Esophageal fistula

(C) Linear ulcers

(D) Pseudomembrane formation

Answer & Explanation

1. Answer: (C) Candida. Explanation: Candida esophagitis accounts for the majority of cases, particularly in immunocompromised patients.

2. Answer: (B) Longitudinal plaque-like lesions. Explanation: Candida typically presents with longitudinal plaques and a shaggy esophageal contour.

3. Answer: (B) AIDS patients. Explanation: CMV esophagitis is strongly associated with advanced HIV/AIDS.

4. Answer: (B) Acyclovir. Explanation: Antiviral therapy with acyclovir is the standard of care for HSV esophagitis.

5. Answer: (B) Esophageal fistula. Explanation: TB esophagitis often leads to fistulas or strictures due to granulomatous necrosis.

References

[1] G. S. Wilcox, "Esophageal infections: Epidemiology, clinical features, and diagnosis," Gastroenterology Clinics of North America, vol. 23, no. 3, pp. 693–716, 2020.
[2] P. D. Smith et al., "Esophageal candidiasis in patients with AIDS," Annals of Internal Medicine, vol. 102, pp. 143–150, 2019.
[3] J. E. Kahrilas and A. I. Katzka, "Esophagitis: Pathophysiology and clinical features," New England Journal of Medicine, vol. 378, pp. 1175–1185, 2018.
[4] H. J. Kim, "Radiographic and endoscopic features of infectious esophagitis," Korean Journal of Radiology, vol. 21, pp. 457–469, 2020.
[5] A. R. Wilcox and S. J. Richter, "Herpes simplex esophagitis in immunocompromised hosts," Clinical Gastroenterology and Hepatology, vol. 15, pp. 442–448, 2021.
[6] R. L. Gandhi, "Cytomegalovirus infection of the gastrointestinal tract," Clinical Microbiology Reviews, vol. 34, no. 2, pp. 145–164, 2019.
[7] B. T. Jeyarajah, "Tuberculous involvement of the esophagus: Case series and literature review," World Journal of Gastroenterology, vol. 27, no. 15, pp. 1824–1833, 2021.

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