Unexplained Giant Esophageal Ulceration in a Pregnant Woman With Severe Immunosuppression

Esophageal ulceration is a well-recognized cause of morbidity in patients with advanced human immunodeficiency virus (HIV) infection, most commonly from opportunistic infections such as cytomegalovirus, herpes simplex virus, or Candida species. Idiopathic esophageal ulceration (IEU) is a diagnosis of exclusion associated with profound immunosuppression, typically with CD4 counts <50 cells/mm³. Its occurrence during pregnancy, particularly in congenital HIV infection, is exceedingly rare and presents unique diagnostic and therapeutic challenges. We report a 32-year-old pregnant woman at 21 weeks' gestation with congenital HIV/AIDS and longstanding nonadherence to antiretroviral therapy (ART) presenting with progressive odynophagia and dysphagia. Evaluation revealed severe immunosuppression (CD4 count 4 cells/mm³, HIV viral load 96,000 copies/mL). Esophagogastroduodenoscopy showed multiple large, deep esophageal ulcers. Histopathologic evaluation with special stains and immunohistochemical studies excluded viral, fungal, and mycobacterial etiologies. HIV-associated IEU was diagnosed. Re-initiation of ART with supportive care resulted in symptomatic improvement within four weeks and subsequent cesarean delivery following preterm labor. This case highlights the importance of early endoscopic evaluation in severely immunocompromised pregnant patients with persistent esophageal symptoms and underscores the critical role of immune reconstitution through ART in managing IEU.