In a prospective study of 154 AIDS patients, 48 (31%) complained of pain on swallowing both liquids and solids and 32 (21%) of these also had dysphagia. While candidiasis was the most common cause of symptoms (26 patients), discrete ulceration of the oesophagus occurred in 12 instances in 10 patients (four cytomegalovirus, four herpes simplex virus, three aphthous ulcer, one peptic ulcer). One patient had a diffuse oesophagitis caused by Mycobacterium avium intracellulare. No cause was found for the oesophageal symptoms in four patients. Kaposi's sarcoma (KS) was found in seven patients associated with other pathology in four. All 26 patients with oesophageal candidiasis only, also had oral involvement. All the patients with herpes simplex virus (four) and aphthous ulcers (three) had obvious perioral involvement. Three of the four patients with cytomegalovirus ulceration had evidence of disease elsewhere (colon or retina). All patients with Kaposi's sarcoma lesions had skin and buccal cavity involvement. The cause of oesophageal disease was usually obvious at endoscopy. The appearance of candidiasis was typical and the various ulcerating lesions also had different macroscopic configurations. Cytomegalovirus infection produced deep linear ulcers in the distal oesophagus, herpes simplex oesophagitis is similar in appearance to the typical perioral lesions of fluid filled vesicles. Diagnostic radiology was not helpful in most patients. In nine of 17 patients with candidiasis, the barium swallow examination performed within 24 hours of presentation was normal. In only three of seven patients with oesophageal ulceration (three cytomegalovirus, two herpes simplex virus, one aphthous, one peptic) was there evidence of an abnormality. Treatment produces symptomatic relief. All patients with candidiasis responded to ketoconazole, the four with herpes simplex virus to acyclovir and one of three with aphthous ulceration had a dramatic response to thalidomide. The three patients with cytomegalovirus infection who were treated with foscarnet had a prolonged remission of symptoms. The overall prognosis of patients with oesophageal symptoms is poor, with an average survival time from a definitive diagnosis of five months (range one to 13).
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