A 27-year-old female was admitted to a local hospital with community-acquired pneumonia. She tested positive for human immunodeficiency virus (HIV) and had a baseline CD4 count of 0 cells/muL. Investigations for tuberculosis were negative. At the time of her discharge, she was started on a fixed-dose combination of antiretroviral therapy (ART) which comprised tenofovir, emtricitabine and efavirenz. Four weeks after initiating ART she began experiencing dysphagia, which was initially only to solids. Empiric fluconazole therapy prescribed by her local clinic did little to alleviate her symptoms which progressively worsened over the ensuing 6 months before presenting to our institution. She described no other symptoms. She did not have diarrhea. She reported no loss of visual acuity. On examination, she was wasted. She had no palpable lymphadenopathy, nor did she have hepatomegaly or splenomegaly. Fundoscopy revealed no evidence of retinitis.
Initial haematological investigations revealed a mild normocytic anemia with a haemoglobin 10.9 g/dL. Tests for renal and liver function were normal. After 6 months of ART, the patient's CD4 count was then 106 cells/muL and she was virologically suppressed with an undetectable viral load. A barium swallow (Fig. 1A) revealed marked narrowing at the distal esophagus. A gastroscopy was performed which confirmed the presence of a distal esophageal stricture. The stricture was biopsied, and the tissue samples sent for histological examination.
Haematoxylin and eosin (H&E) sections were entirely representative of granulation tissue surfaced in areas by fibrinopurulent material, consistent with ulceration. No intact mucosa was identified. The inflamed granulation tissue comprised neovascularisation and reactive fibroblasts amidst a mixed inflammatory cell infiltrate of lymphocytes, neutrophils and eosinophils. Within the granulation tissue, isolated foci of larger, atypical cells displaying nucleomegaly were identified (Fig. 1B). Futher investigation included Ziehl-Neelsen (ZN) and Alcian blue - Periodic acid-Schiff (AB-PAS) histochemical stains, as well as CMV immunohistochemistry. CMV immunohistochemical stains highlighted the presence of multiple foci of cells showing strong, nuclear staining, confirming the presence of CMV infection (Fig. 1C). ZN and AB-PAS stains showed no acid-fast bacilli nor fungal elements, respectively.
The patient was commenced on ganciclovir 5 mg/kg intravenously twice a day for 14 days and underwent esophageal dilatation with good result. She was discharged home shortly thereafter being able to tolerate solid foods with no symptoms of dysphagia.