A 28-year-old HIV-positive woman (CD4 count 95 cells/μL) presents with 2 weeks of progressive dysphagia and retrosternal pain. Endoscopy reveals large, discrete, linear ulcers in the mid-esophagus. Biopsy shows intranuclear inclusions with a 'owl's eye' appearance. What is the most likely diagnosis?

• A Herpes simplex virus esophagitis
• B Cytomegalovirus esophagitis ✓
• C Candida esophagitis
• D Idiopathic esophageal ulcer (HIV-associated)

Explanation

CMV esophagitis typically presents with large, solitary or few discrete ulcers (often >1 cm) in the mid to distal esophagus. The 'owl's eye' intranuclear inclusion is pathognomonic for CMV. HSV causes multiple small, discrete, volcano-like ulcers. Candida shows white plaques that are adherent. Idiopathic esophageal ulcers can mimic CMV but lack viral inclusions on biopsy.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.