Use of a new cytology balloon for diagnosis of symptomatic esophageal disease in acquired immunodeficiency syndrome

Prospective comparison of brush cytology, viral culture, and histology for the diagnosis of ulcerative esophagitis in AIDS

BACKGROUND & AIMS

The best method(s) for the diagnosis of esophageal ulcers in patients with acquired immune deficiency syndrome (AIDS) is unknown.

METHODS

Over an 8-year period, all human immunodeficiency virus (HIV)-infected patients with a CD4 lymphocyte count of < or =250/mm(3) and an esophageal ulcer underwent a standard protocol consisting of 2 biopsy examinations for viral culture (shell vial technique), brushing for cytology with immunohistochemistry (IHC) for viral antigens, and 10 biopsy examinations of the ulcer base/edge for routine histology and IHC. The cause of ulcer was based on histologic findings and clinical and endoscopic follow-up evaluation after therapy.

RESULTS

Forty patients with 48 episodes of ulcer were studied (mean age, 34 yr; 88% men; median CD4 lymphocyte count = 31 cells/mm(3); range, 0-250 cells/mm(3)). Six patients had more than one endoscopic examination documenting ulcer, and 2 patients had more than one cause of ulcer. The most common causes of ulcer were: idiopathic (IEU) 22, cytomegalovirus (CMV) 15, and gastroesophageal reflux disease 6. Viral culture was positive for herpes simplex in 3 of 3, but only 4 of 15 (27%) for CMV, and specificity of viral culture was 100%. Cytologic brushings were only positive in the patients with herpes simplex virus (HSV) or incidental Candida esophagitis. Viral cytopathic effect was apparent on routine histologic staining in each patient with viral esophagitis, and IHC confirmed the diagnosis in each patient. Follow-up evaluation disclosed no patient with a misdiagnosis based on histology.

CONCLUSIONS

Viral culture and cytologic brushings add little to the evaluation of esophageal ulcers in patients with AIDS over multiple biopsy specimens with routine histology.

Cytology in Barrett's esophagus

Brush cytology is complementary to endoscopic biopsy and is recommended by some to be part of the routine endoscopic surveillance of patients with BE. Advantages of cytology include the ability to sample a greater area of involved epithelium, preferential exfoliation of the less cohesive dysplastic cells, simplicity, and lower cost. There are clear cytologic criteria for dysplasia, and biomarker studies can be performed on cytologic specimens. Despite these advantages, cytology is used by only 17% of gastroenterologists in the United States today. Limited data are available on the usefulness of cytology in the diagnosis and surveillance of BE. Cytology has good sensitivity for the detection of adenocarcinoma and HGD and good specificity for the detection of IM without dysplasia. Furthermore, cytology may detect abnormalities missed by biopsy. Cytology has problems in the detection of LGD, however. For cytology to become a useful surveillance option, its sensitivity for low-grade lesions must be improved. One potential way to accomplish this is to add biomarkers to routine cytologic specimens to define patients at increased risk of progression to cancer. If simple prognostic biomarkers could be developed and validated in histology and cytologic specimens, this would provide additional support for the utility of cytologic brushings in the surveillance of BE. Cytology could then conceivably accomplish the goals of improved efficiency, risk stratification, and decreased costs in BE surveillance programs.

Cytologic detection of Trichomonas esophagitis in a patient with acquired immunodeficiency syndrome

Trichomonads are pathogens of the female genital tract and colonizers of the oropharynx. Gastrointestinal and pulmonary diseases have been reported in association with Trichomonas species, but a direct pathogenic effect of this organism in these organ systems remains controversial. Esophageal disease due to trichomonads has not been previously reported. A 43-yr-old man with acquired immunodeficiency syndrome (AIDS) with odynophagia and esophageal erosions was evaluated by endoscopy. Cytologic brushings from three of four sites in the esophagus were positive for trichomonads. Treatment with metronidazole resulted in clearance of the organism from the esophagus and improvement in clinical symptoms. We report esophageal trichomoniasis diagnosed on esophageal brush cytology in a man with AIDS. Clinical response was confirmed by cytologic studies and odynophagia improved with metronidazole treatment. Study of cytologic preparations was superior to biopsy for identification of this organism and was particularly useful in following the post-treatment course of disease.

Oral and esophageal disorders

This article focused on the approach to oral and esophageal disorders in patients with AIDS. Most of these disorders respond to various therapeutic regimens. Some of the oral complications can be prevented with dental prophylaxis, whereas recurrent esophageal disease in some patients may require long-term suppressive therapy. As patients with AIDS live longer with lower CD4 counts, gastroenterologists need to become familiar with the approach to and management of the more common lesions of the mouth and esophagus.