A 36-year-old man with HIV (CD4 count 70 cells/μL) reports 3 weeks of painful swallowing with retrosternal discomfort. Oral examination shows white plaques that scrape off leaving an erythematous base. He is able to swallow liquids. What is the most appropriate next step?

• A Immediate upper gastrointestinal endoscopy before any treatment
• B Empirical oral fluconazole for Candida oesophagitis ✓
• C Intravenous ganciclovir for cytomegalovirus oesophagitis
• D Proton pump inhibitor trial for reflux oesophagitis

Explanation

Odynophagia with visible oral thrush in an immunosuppressed patient allows empirical diagnosis of Candida oesophagitis, treated with systemic fluconazole for 14 to 21 days. Endoscopy is reserved for patients who fail empirical therapy or lack oral candidiasis, where large linear distal ulcers suggest CMV oesophagitis and giant ulcers suggest aphthous ulceration. B proton pump inhibitor trial would delay appropriate antifungal treatment in a patient with clear thrush.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.