For 1 month, a 60-year-old white man has had increasing fatigue, generalized weakness, and exertional dyspnea. He becomes short of breath after he walks only 100 to 150 yards on level ground or climbs only 1 flight of stairs. In addition, he has unintentionally lost 12 lb in the past month and has experienced intermittent dysphagia with solid foods. He attributes this last symptom to long-standing gastroesophageal reflux disease (GERD), for which he regularly takes over-the-counter omeprazole.
He denies fever, rigor, chills, night sweats, rashes, arthralgias, headaches, vision problems, paresthesias, weakness, and ataxia. He has no cough, chest pain, or palpitations, but he has minimal ankle swelling in the evening. His appetite has been poor, resulting in decreased caloric intake, but he does not have nausea, vomiting, diarrhea, constipation, abdominal distention, hematemesis, or jaundice. He has noted no increased bleeding tendency or urinary symptoms.
History. He has had no surgeries. He has smoked 1 or 2 cigars a day for the past 20 years; he does not drink alcohol. He has no history of foreign travel, blood transfusion, or allergies. His father has type 2 diabetes, and his mother died of breast cancer.
Examination. The patient is pale but is not in undue distress at rest. Heart rate is 104 beats per minute; respiration rate, 20 breaths per minute; and blood pressure, 140/76 mm Hg. He is afebrile and well hydrated. No adenopathy is noted. His thyroid gland is not palpable. There is 1+ bilateral ankle edema.
Jugular venous pressure is normal and peripheral pulses are strong. The apex feels normal, and both heart sounds are clearly audible. A musical, grade 2 systolic murmur can be heard over the entire precordial area; however, no gallop is audible. Lungs are clear and abdomen is normal. Results of a rectal examination are normal; results of a guaiac stool test are positive. The patient is neurologically intact.
Laboratory studies. A complete blood cell count reveals a hemoglobin level of 6 g/dL. Laboratory evaluation reveals the following levels: serum iron, 30 μg/dL; total iron binding capacity, 510 μg/dL; and serum ferritin, less than 12 μg/L. Other laboratory values are normal, as are urinalysis results.
A chest radiograph shows no acute infiltrates. Results of a tuberculin skin test are negative. No pathogens are isolated from 2 blood cultures.
Based on the clinical picture and laboratory and endoscopy findings, what is the most likely diagnosis?
•Esophageal candidiasis.
•Barrett esophagitis.
•Cancer of the esophagus.
•Hiatal hernia.
•Herpes esophagitis.
(Answer on next page.)
