A HIV positive man with CD4 count of 25 presented with complaints of painful swallowing for the past 2 days. He never had similar issues in the past. The patient has been non-compliant with his HAART medications and PCP prophylaxis. The patient also reports that three days ago, he visited the ER for a cold sore on his lip and he was started on Acyclovir orally by the ER physician. On physical examination he is febrile with temperature of 101F. There is no thrush or pharyngeal erythema. You start the patient on emperic therapy with fluconozole and ask him continue acyclovir. However, his symptoms continue to worsen after one week of emperic therapy. A decision is made to perform endoscopy for further diagnosis . Clinically, the most likely etiology of this patient’s odynophagia is :
A) Resistant Esophageal Candidiasis
B) HSV esophagitis
C) Pill induced Esophagitis
D) Gastro esophageal Reflux disease
E) Esophageal cancer
F) CMV esophagitis
Archer USMLE Step 3 Blog 
f
If pt has oral thrush,treat empirically with Fluconazole for 2 weeks,if symptoms does not improve then endoscopy
Endoscopic Findings for Herpes simplex
->deep ,small multiple leison-Rx-Acyclovir
CMV-Superficial Large Leison
Rx-Ganciclovir
F
f. CMV
Esophagitis in HIV may be due to
Candida (the most common cause is Candida): The patient with severe odynophagia, without dysphagia or thrush, is more likely to have ulcerative esophagitis, such as herpes simplex virus, rather than Candida.
herpes simplex virus: Patients usually present with odynophagia and dysphagia. Fever, epigastric pain, nausea, vomiting, and heartburn are less frequent. And patient deteriorated on acyclovir which is toc
cytomegalovirus:CMV esophagitis presents with fever, odynophagia, and nausea, and is occasionally accompanied by substernal burning pain. Endoscopy will show extensive, large, shallow ulcers or erosions in the distal esophagus. Treatment is with gancyclovir.
or aphthous ulcers:
B, i guess,since the patient has only odynophagia (means painfull swallowing )not any clue for dysphagia. and he had an obvious cold sore (hsv) lesion on his lips and since he is noncompliant with his HAART regimen that can cause a vulnerable systemic dis.
Likely F althoguh A and B are also applicable. As the svereity of HIV/AIDS increases and the more imuunosupressed they become, the likelihood of CMV and other infections increases. He was on fluco and acyclo with no help. Thus, it is either resistance or a different infection. Resistance might be either to fluco or acyclo and sicne we dont have acyclo resistance in options, and since pt has already tried acyclo which should have helped HSV, neither A nor B is true. Which leaves F as the most likely asnwer.