Esophageal stricture from idiopathic ulcers in an AIDS patient: a case report and review of the literature

Surgical implications of human immunodeficiency virus infections

Pediatric HIV (human immunodeficiency virus) is a pandemic predominantly in sub-Saharan Africa. Approximately 2.2 million children aged less than 15 years are infected with HIV, representing almost 95% of the total number of children globally infected with HIV. Therefore, increasing numbers of HIVi or -exposed but uninfected children can be expected to require a surgical procedure to assist in the diagnosis of an HIV/acquired immune deficiency syndrome-related complication, to address a life-threatening complication of the disease, or for routine surgery encountered in HIV-unexposed children. HIVi children may present with both conditions unique to HIV infection and surgical conditions routine in pediatric surgical practice. HIV exposure confers an increased risk of complications and mortality for all children after surgery, whether they are HIV infected or not. This risk of complications is higher in the HIVi group of patients. These findings seem to be independent of whether patients undergo an elective or emergency procedure, but the risk of an adverse outcome is higher for a major procedure. Surgical implications of HIV infection are comprehensively reviewed in this article.

Human Immunodeficiency Virus–Related Gastrointestinal Pathology: A Southern Africa Perspective With Review of the Literature (Part 2: Neoplasms and Noninfectious Disorders)

Context.—Human immunodeficiency virus (HIV) infection is rife in sub-Saharan Africa and in southern Africa in particular. Despite the increasing availability of antiretroviral therapy in this region, HIV-associated neoplasms remain common and frequently involve the gastrointestinal tract, which may also demonstrate other noninfectious, HIV-related pathology.

Objective.—To review the histopathologic findings and distinguishing features of neoplastic and noninfectious, HIV-associated gastrointestinal disorders in southern Africa and relate those findings to the documented international literature.

Data Sources.—The available literature on this topic was reviewed and supplemented with personal experience in a private histopathology practice in South Africa.

Conclusions.—In southern Africa, a diverse range of HIV-related neoplasms and noninfectious gastrointestinal disorders is seen, but published data for the region are scarce. The gastrointestinal disorders include drug-associated pathology, gastrointestinal manifestations of the immune reconstitution inflammatory syndrome, idiopathic chronic esophageal ulceration, and the controversial entity of HIV enteropathy.

Complete esophageal obliteration secondary to cytomegalovirus in AIDS patient

HIV-related benign esophageal strictures have been reported secondary to idiopathic esophageal ulceration, cytomegalovirus (CMV) esophagitis, herpetic esophagitis, and increased sensitivity to radiation therapy. Despite extensive and deep nature of CMV ulceration, stricture formation is uncommon. There have been anecdotal reports of esophageal strictures secondary to CMV infection in HIV patients. Esophageal stricture has been reported during active CMV ulceration as well as subsequent to successful treatment. Esophageal strictures secondary to CMV have also been reported without prior ulceration. We report a patient with CMV esophagitis presenting with ulceration and stricture who developed total obliteration of esophageal lumen following treatment with gancyclovir.

Advantages and pitfalls of the polymerase chain reaction in the diagnosis of esophageal ulcers in AIDS patients

HIV-1-infected patients frequently have opportunistic esophageal infections which, when associated with severe immunodeficiency, can be attributed to unusual pathogens. The clinical presentation of several esophageal diseases is similar and the best method for a specific diagnosis of these patients has not been well defined. To evaluate the role of the polymerase chain reaction (PCR) in the etiologic definition of esophageal ulcers in HIV-1-infected patients, 96 esophageal biopsies from 79 HIV-1-infected patients were processed by PCR using specific primers for cytomegalovirus (CMV), herpes virus (HSV), human papilloma virus (HPV), HIV-1, Mycobacterium tuberculosis, Mycobacterium avium, Mycobacterium intracellulare, Treponema pallidum, and Haemophilus ducreyi. The PCR results were compared to the histopathologic results. Seventy-nine patients were studied (mean age: 34 years; 62% men; median CD4 + T cell = 103.59 cells/microl (range 1-795.2 cells/microl). The most common endoscopic findings were as follows: esophageal candidiasis (37.1%), esophageal ulcers (24.7%), esophagitis (11.2%), and lugol-negative areas (10.1%). The histopathologic findings in the esophageal ulcers (22 biopsies) were non-specific inflammation (31.8%), HSV (36.4%), Candida (13.6%), CMV (13.6%), or HPV disease (4.5%). In the esophageal ulcer biopsies, the PCR results were negative in 27.6% of cases, and positive for HIV (65.5%), CMV (31%), HPV (20.7%), HSV (10.3%), and H. ducreyi (6.9%). The histopathologic examination did not identify a pathogen or identified only Candida in 15 biopsies of esophageal ulcers. PCR was positive in ten (66.7%) and negative in five (33.3%) of these biopsies (idiopathic ulcers). PCR detected: HIV (53.3%), CMV (20%), HPV (13.3%), and H. ducreyi (6,7%). PCR detected more etiologic agents in esophageal ulcers than histopathology and was able to detect unusual pathogens. On the other hand, sometimes more than one pathogen was detected in the esophageal ulcers, making it difficult to reach an accurate diagnosis. This finding indicates the need for more studies to evaluate the benefit of this method in the routine evaluation of esophageal ulcer biopsies in HIV-1-infected patients.

Esophageal giant ulcer in primary human immunodeficiency virus infection is associated with an infiltration of activated T cells

Primary human immunodeficiency virus (HIV) infection is a rarely diagnosed disease. The intestinal lymphocyte population represents a primary target of infection, virus replication, as well as cell infiltration and activation. The purpose of this study was to describe a patient suffering from esophageal giant ulcer as a clinical manifestation of primary HIV. In the present case of primary HIV infection a giant ulcer of the esophagus was diagnosed as the clinical manifestation. An upper endoscopy was performed and the biopsy specimens were further processed for immunohistochemical stainings characterizing the cellular infiltrate as well as cytokine production. In addition, seroconversion was documented and total viral load was determined. The esophageal ulceration presented the clinical manifestation of primary HIV infection since other causes of esophageal ulcerations could be excluded. The ulceration revealed an inflammatory infiltrate consisting of both CD4(+) and CD8(+) T cells. The vast majority of these cells expressed the activation marker CD38 and several cells showed interferon-gamma and interleukin-2 production. Furthermore, a substantial number of tissue infiltrating CD8(+) T cells expressed the cytotoxic molecule perforin. In addition, the HIV antigen p24 could be detected in the inflammatory infiltrate. Subsequent steroid treatment resulted in a relief of symptoms and healing of the ulcerations. These observations strongly suggest that infiltration of activated T cells plays a crucial role in the pathogenesis of giant ulcers during primary HIV infection.