Epidemiology and predisposing conditions

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In the recent years the spectrum of infectious esophagitis in childhood has expanded, owing to the emergence of new conditions, such as the acquired immunodeficiency syndrome (AIDS), the advancement in therapy and survival of patients transplanted and treated with immunosuppressive drugs, and the improvement in endoscopic and microbiological techniques. The most common infectious causes of esophagitis are fungal, viral, bacterial and, more rarely, protozoal. Primary esophageal infection is quite rare in otherwise normal subjects without permissive factors and most cases of infectious esophagitis are described in immunocompromised patients.

The immunocompetent subjects developing esophageal infections will have predisposing conditions that weaken defence mechanisms of the esophageal mucosa. Esophageal disorders that cause slowing of peristalsis and stasis of intraluminal content such as achalasia, systemic sclerosis, myopathies, neuropathies and esophageal strictures predispose to infections of the eso-phageal mucosa, usually candidiasis. Infections in the surrounding organs and structures may also involve the esophagus. Other conditions predisposing to esophageal infections are malnutrition and diabetes mellitus. The latter may derange esophageal peristalsis and emptying of intralumi-nal content, and may impair granulocyte function through hyperglycemia. Finally, antimicrobial drugs can alter the normal oropharyngeal flora leading to overgrowth of Candida organisms.

Conditions affecting both humoral and cellular immunological variables also lead to esophageal infections. This occurs in children with either genetic or acquired immunodeficiency as well as in the course of diseases promoting development of opportunistic infections. Transplant recipients are candidates for infectious esophagitis through different mechanisms: drug-induced immunosuppression, chemotherapy and neutropenia. Furthermore, whereas bacterial and fungal infections predominate in the early phases following transplantation, when granulocyte number and function are more compromised, the cytomegalovirus (CMV) infection occurs a few months after transplantation when T-cell function is more impaired.

In HIV-infected patients opportunistic infections develop and increase in frequency as immunodeficiency worsens. Esophageal and other opportunistic infections do not occur until immunodeficiency is severe, usually when the CD4 lymphocyte count is below 100-200/mm3, according to references 1-3. More recently, however, the widespread availability of highly active antiretro-viral therapy has been associated with an apparent decline in opportunistic infections in HIV-infected patients. The causes of esophageal disease in patients with HIV infection and AIDS are reported in Table 3.1. In contrast to the findings in other immunocompromised hosts, herpes simplex virus (HSV) esophagitis is uncommon, whereas by far the most common cause is Candida, accounting for about 50% of esophageal infections.4,5 Esophageal candidiasis can also co-exist with other esophageal infections.6

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