A 38-year-old man with AIDS (CD4 count 35 cells/μL) presents with 3 weeks of progressively painful swallowing and retrosternal pain. He has no oral thrush. Endoscopy reveals several large, well-circumscribed, shallow ulcers in the distal oesophagus; brushings are negative for fungal elements and biopsies show endothelial cells with intranuclear owl-eye inclusions. What is the most appropriate initial therapy?

• A Oral fluconazole 400 mg daily
• B Oral itraconazole solution
• C Intravenous ganciclovir ✓
• D Oral prednisolone taper

Explanation

Large discrete distal oesophageal ulcers without candidal organisms, plus cytomegalic intranuclear inclusions in endothelial cells, establish CMV oesophagitis, treated initially with intravenous ganciclovir (or valganciclovir) followed by maintenance until immune recovery. Fluconazole kills the best distractor: it would be the correct empirical step only if oral thrush were present or fungal elements seen, neither of which applies here. Steroids have no role in infectious oesophagitis in advanced immunosuppression.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.