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Case 45

28-year-old HIV-positive patient is referred because of suspected candidal esophagitis

I noticed them about 3-4 weeks ago.

The time course can offer clues for the differential diagnosis.

I am HIV-positive.

Wouldn't it be unfortunate to overlook this point?

I have tried to brush them away with my toothbrush, but they are stubborn.

A critical question, as thrush (most common candidal infection of mouth) is easily removed.

No, not at all.

Oral pain always demands prompt treatment, as it interferes with eating and drinking.


A total body check is always wise, and especially in the case of HIV, which has so many possible cutaneous findings.


Always a good question when confronted with oral mucosal lesions; here it plays no role.

Choose the right efflorescences:

Vesicles are fluid-filled, and not seen here.

Here is a type of papule—a white plaque which on the oral mucosa is usually described as leukoplakia.

Scales are never found in the mouth. The saliva and mechanical pressures do not let them form.

There is no epithelial defect here.

Choose the right diagnosis:

The key question, but candidal plagues are easily removed. KOH examination and biopsy can decide the question. A positive candidal culture from the mouth is not helpful.

Lichen planus typically has patches with a white lacy network (Wickham striae) or erosions.

Very good. The clinical picture with location on the side of the tongue is perfect. The appearance of oral hairy leukoplakia suggests a progression of HIV.

Pemphigus vulgaris presents with oral bulla and erosions.

The tongue can be burned, but then it becomes erythematous, perhaps eroded, and heals quickly.

Choose the right therapy(ies):

Worth a try.

In experienced hands, sometimes helpful, but officially podophyllin should not be used in the mouth.

The treatment of choice; as the HIV infection is controlled, the oral hairy leukoplakia will improve.

No reason to think this would help.

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