These patients share one principle: the mucosa was injured by something that touched it, whether an organism the host could not keep down, a tablet that lodged where the lumen narrows, or a swallowed corrosive. Depth reflects contact time, site reflects local anatomy, and host status reflects who is vulnerable. That framework sorts the differential before the scope. The case. An HIV patient with a CD4 count of 40 has odynophagia and one large, deep, serpiginous distal ulcer on endoscopy. Where do you biopsy, and what organism are you looking for? Topics covered Candida: the most common infectious esophagitis, white adherent plaques The host spine: HIV with CD4 under 200, inhaled steroids, transplant, antibiotics HSV: shallow volcano-edge ulcers, epithelial inclusions at the ulcer edge CMV: large deep serpiginous ulcers, stromal inclusions at the ulcer base The biopsy-site rule: HSV from the edge, CMV from the base Treatment: fluconazole, acyclovir, ganciclovir by organism Pill esophagitis: kissing ulcers at the aortic arch, offending drugs and technique Caustic injury: acid versus alkali, the role and timing of endoscopy When to biopsy versus treat empirically for Candida Key decisions Host status sorts the infectious differential before biopsy: Candida with inhaled steroids or CD4 under 200, CMV with CD4 under 50 Biopsy site is the exam trap: HSV lives in the epithelium at the ulcer edge, CMV in the stroma at the ulcer base A classic Candida host with typical plaques can be treated empirically with fluconazole; viral or pill features push to biopsy first Pill esophagitis is a history diagnosis (a specific tablet taken with little water); stop the drug and coach technique Caustic ingestion is graded endoscopically within the first 24 to 48 hours; avoid blind instrumentation of a deeply injured esophagus For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - Opening: injured by something that touched it (01:30) - Candida and the immunocompromise workup (05:00) - HSV: edge ulcers and epithelial inclusions (07:30) - CMV: base ulcers and stromal inclusions (09:30) - The biopsy-site rule and treatment by organism (12:00) - Pill esophagitis and caustic injury

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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