We read with interest the recent report by Wilcox and associates [1] and noted two outstanding findings: 1) the high prevalence of idiopathic esophageal ulcers and the excellent initial response to prednisone therapy and 2) the high percentage of patients with ulcer recurrence. In 13 of 35 patients with esophageal ulcers (37.1%), ulcerations recurred despite an initial clinical and endoscopic response [1].

We have recently cared for seven HIV-infected patients who had idiopathic esophageal ulcers. All had advanced disease. Three patients were initially treated with a 2-week regimen of prednisone, 0.5 mg/kg of body weight per day, but clinical and endoscopic relapse was documented between 2 and 4 weeks after the prednisone dose was tapered. Four patients initially received thalidomide, 100 mg/d for 10 days, and symptoms rapidly disappeared after treatment began. After a follow-up period of 4 to 10 months, ulceration had not recurred in our patients. In all the prednisone recipients who had ulcer recurrence, a course of thalidomide resulted in resolution of clinical symptoms and ulcer healing. No recurrence was documented in two patients during follow-up periods of 11 and 16 months, respectively. In another patient, numerous episodes of ulcerations occurred, despite effective courses of thalidomide therapy. The patient died 5 months after the first episode.

Recurrence of idiopathic esophageal ulcers may represent an important problem in HIV-infected patients, both from a diagnostic and nutritional viewpoint, as Wilcox and colleagues reported [1]. Although prednisone therapy is useful for the initial treatment of HIV-associated esophageal ulcers, disease will recur in more than a third of patients [1, 2]. In our experience and in that of others [3, 4], thalidomide has been very effective in treating HIV-associated ulcerations, including idiopathic esophageal ulcerations that had not responded to prednisone therapy. Although no conclusions can be drawn from our limited number of cases, our experience is encouraging because it suggests that thalidomide can be used both as a first-choice drug or as a safe alternative to corticosteroid therapy in HIV-infected patients with idiopathic esophageal ulcerations.