Bnef Report Esophageal Ulceration Related to

Zalcitabine (dideoxycytidine, ddC) is an antiretroviral agent whose efficacy in the management of human im-munodeficiency virus (HIV) infection is currently being studied. We report a case of recurrent esophageal ul-ceration in a patient taking zalcitabine. Case Report A 20-year-old white man with progressive HIV infec-tion (CD4 lymphocyte count 50 cells//LtL but no AIDS-defining illness) was enrolled in a randomized, double-blind study of zalcitabine compared with zidovudine on 7 June 1990. He had no history of esophageal or gas-trointestinal disease before he entered the study. His only medications were clotrimazole troches and monthly aerosolized pentamidine. On 22 June the pa-tient complained of an acneiform rash and was pre-scribed doxycycline, which he discontinued after 2 days because of nausea. Shortly thereafter, he began experi-encing increasing dysphagia, odynophagia, and retro-sternal pain. Figure 1 shows the patient's clinical course. Ranitidine was administered empirically, fol-lowed by fluconazole and acyclovir after an esophagram showed midesophageal ulcerations. The patient failed to improve and was hospitalized; upper gastrointestinal en-doscopy showed "kissing " esophageal ulcers at 30 cm and superficial gastric erosions. All histopathologic studies (including those for candidiasis, herpes viruses, and malignancies) were negative, showing only nonspe-cific inflammation. The patient clinically responded to a tapering course of prednisone. His study drug, discon-tinued 10 July, was resumed 2 weeks later when he was asymptomatic. Within 3 weeks he again began experi-encing odynophagia and retrosternal pain. Prednisone was re-started after a second esophagram showed ulcer-ation of the midesophagus; he again responded clini-cally and his study drug was continued. The patient did well until late October when he ex-perienced recurrent esophageal symptoms; a third esophagram showed a solitary, midesophageal ulcer that was 3.8 cm long. The study drug was withdrawn, and esophagrams on 12 and 26 November showed gradual improvement of the ulcer. The patient became asymp