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Idiopathic esophageal ulceration is nearly forgotten in an era of controlled human immunodeficiency virus.

Obstruction due to esophageal ulceration is usually caused by gastroesophageal reflux disease, malignancy, or eosinophilic esophagitis. In patients infected with the human immunodeficiency virus (HIV), another specific cause of obstruction should not to be forgotten. A 43-year-old HIV-infected man with low CD4 cell count and high viral load was admitted with odynophagia and dysphagia. Esophagogastroduodenoscopy showed severe esophagitis with strictures (●" Fig.1 and●" Fig.2), and normal histology on repeat endoscopy. Multiple dilations and subsequent high-dose proton pump inhibitors and ganciclovir did not improve the symptoms. Serology for herpes simplex virus and cytomegalovirus was negative. Meanwhile, viral loads and CD4 cell count improved, as a result of adjustment to antiretroviral therapy. Finally, a gastroenterologist who was experienced in HIV problems suggested the diagnosis of HIV-associated idiopathic esophageal ulceration (IEU). The patient was treated with liquid steroids (beclomethasone), which resulted in clinical and endoscopic improvement (●" Fig.3). In the early days of the acquired immunodeficiency syndrome epidemic, gastroenterologists frequently encountered complications. IEU was typically seen in patients with uncontrolled HIV, as in the current patient. With increasingly wellmonitored HIV treatment, IEU has become rare. Current gastroenterologists and internists are less familiar with diagnosing IEU, which should also be considered in other immunocompromised patients (e.g. stem cell or renal transplantation) [1,2]. In addition, fragmentation of care may further delay proper treatment. In the 1990s, one group reported an IEU prevalence of 15% in HIV patients [3]. Typical symptoms were chest pain and odynophagia; dysphagia was less common. Histology is mandatory to exclude malignancy and infection. The treatment of choice is steroids, with response in 90% of patients [4–6]. With thalidomide, a success rate of 71% was reported [7]. The current patient was successfully treated with orally administered enema steroids (beclomethasone). The influence of better viral control with interventions other than steroids is unknown. No data exist comparing the latter. Budesonide inhalers, prescribed for eosinophilic esophagitis, might be newadditions to the armamentarium. In summary, early recognition of IEU is warranted in order to start treatment.