A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 27-year-old woman presents with painful swallowing for the past 2 days. She received a kidney transplant 3 months ago for lupus-induced end-stage renal disease. She takes tacrolimus, mycophenolate mofetil, prednisone, and calcium supplements. The blood pressure is 120/80 mm Hg, the pulse is 72/min, the respirations are 14/min, and the temperature is 38.0°C (100.4°F). Esophagoscopy shows serpiginous ulcers in the distal esophagus with normal surrounding mucosa. Biopsy shows large cytoplasmic inclusion bodies. Which of the following is the most appropriate pharmacotherapy at this time?
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A
BudesonideIncorrect. Budesonide treats eosinophilic esophagitis (food impaction, dense eosinophilic infiltrate), not CMV.
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B
FluconazoleIncorrect. Fluconazole treats Candida esophagitis (white plaques on endoscopy, pseudohyphae on biopsy), not CMV with inclusion bodies.
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C
GanciclovirCorrect. CMV esophagitis (serpiginous distal ulcers, large nuclear and cytoplasmic inclusions) in an immunosuppressed transplant patient is treated with IV ganciclovir.
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D
PantoprazoleIncorrect. Pantoprazole treats reflux esophagitis but does not address a viral infection in an immunocompromised patient.
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E
Nystatin swish-and-swallowIncorrect. Nystatin treats oropharyngeal candidiasis (thrush) but does not penetrate well into esophageal mucosa and is not effective against CMV, which requires systemic ganciclovir.
↑ Tap an answer to reveal the reasoning
Answer: C. A solid-organ transplant recipient on tacrolimus, mycophenolate, and prednisone develops painful odynophagia and esophagoscopy reveals SERPIGINOUS ulcers in the DISTAL esophagus with normal intervening mucosa, and biopsy shows large CYTOPLASMIC (and intranuclear) inclusion bodies — this is classic for CMV (cytomegalovirus) esophagitis. CMV produces deep, linear/serpiginous distal esophageal ulcers; on histology, CMV-infected endothelial and stromal cells show 'owl's eye' intranuclear inclusions and basophilic cytoplasmic inclusions. Treatment is IV ganciclovir (foscarnet is second-line for ganciclovir-resistant CMV).
Key distinctions among immunocompromised esophagitis: HSV esophagitis causes shallow, well-demarcated 'volcano' ulcers (multiple small ulcers) and shows Cowdry type A intranuclear inclusions with multinucleated giant cells — treated with acyclovir. Candida esophagitis causes adherent white plaques (not ulcers) — treated with fluconazole.
Budesonide is for eosinophilic esophagitis; pantoprazole for reflux — neither addresses an opportunistic infection.
**Why each option:**
**A.** Budesonide treats eosinophilic esophagitis (food impaction, dense eosinophilic infiltrate), not CMV.
**B.** Fluconazole treats Candida esophagitis (white plaques on endoscopy, pseudohyphae on biopsy), not CMV with inclusion bodies.
**C.** Correct. CMV esophagitis (serpiginous distal ulcers, large nuclear and cytoplasmic inclusions) in an immunosuppressed transplant patient is treated with IV ganciclovir.
**D.** Pantoprazole treats reflux esophagitis but does not address a viral infection in an immunocompromised patient.