Pain with swallowing

OBJECTIVES:

  • Evaluate a patient with odynophagia

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CASE 1

A 45 yo M with no known PMH presents with inability to tolerate food and painful swallowing x 2 weeks. He first noticed symptoms ~ 4 months ago but they were mild and intermittent. Over the past 2 weeks, he’s lost 15 lbs and has been unable to tolerate both solids and liquids. He has severe midline chest pain with swallowing and states that “food tastes funny”.

He has taken some ibuprofen over the counter that initially helped with symptoms but now cannot swallow any pills. He otherwise denies fevers/chills, night sweats, abdominal pain, nausea/vomiting or diarrhea.

He reports a history of childhood asthma but has not symptoms and is not on any inhalers. He is a homosexual male and has been monogamous over the past year and sexually inactive over the past 4 months. He gets regular testing for STDs, most recently 1 year ago. He routinely uses barrier contraception but ~6 months ago had an unprotected sexual encounter with his partner. He denies any IV drug use.

On physical exam, he is thin but not cachectic and in no acute distress. Hix exam is only notable for dry mucus membranes and small white plaques on his hard palate and in his posterior oropharynx.

His initial lab reveal a normal BMP. CBC shows leukopenia with WBC of 2.3 with decreased lymphocytes.


What is your differential?


How would you manage this patient?


What additional work-up would you want?


FINAL DIAGNOSIS:

How is it diagnosed or treated? 


CASE 2:

A 44 yo M with a history of pemphigus vulgaris who presents with 4 days of severe pain with swallowing. He has a history of well controlled pemphigus vulgaris with cutaneous and oropharyngeal involvement. He was previously treated with 2 doses of rituximab ~ 8 months ago with good control of disease. He has been on tapering steroids since his rituximab infusions and was decreased to 15 mg every other day ~ 1 month ago. He continues to have stable residual disease in two areas on his buccal mucosa and one small area on his scalp.

Four days ago, he noticed throat pain with swallow and an intense burning substernal pain. He also endorses a sensation of food being “stuck in his chest” that occurs with both liquids and solids. He reports thirst, feeling dehydrated, but no weight loss.

On physical exam, he has normal vital signs. His exam was notable for two small shallow ulcerations on buccal mucosa with a white basev without surrounding erythema consistent with is residual pemphigus. No vesicular lesions were around oral mucosa or on lips. The rest of exam was unremarkable. His basic labs including BMP and CBC are all within normal limits.


What is your differential?


CASE CONTINUED:

GI was consulted and he underwent an EGD which showed several linear esophageal ulcerations.

Biopsies revealed IgG and C3 suprabasal intercellular deposition, suprabasal bullous formation consistent with pemphigus vulgaris. Fungal, CMV, and HSV testing was negative.


FINAL DIAGNOSIS:

TAKE HOME POINTS:


REFERENCES:

  1. Kauffman, CA. Clinical manifestations of oropharyngeal and esophageal candidiasis. In: Uptodate, Mitty, J (Ed), UpToDate, Waltham, MA. (Accessed on May 25, 2017).
  2. Pappas, PG, et al. 2009. Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 48:503-535.
  3. Nishimura, S, et al. 2013. Factors Associated with Esophageal Candidiasis and Its Endoscopic Severity in the Era of Antiretroviral Therapy. PLoS ONE, 8(3), e58217. http://doi.org/10.1371/journal.pone.0058217
  4. Samonis, G, et al. Oropharyngeal Candidiasis as a Marker for Esopahgeal Candidiasis in Patients with Cancer. Clinical Infectious Disease. 27 (2): 283-286.
  5. Kniesel, A & Hertl, M. 2011. Autoimmune bullous skin diseases. Part 1: Clinical manifestations. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 9: 844–857.