A Case Report of Herpes Esophagitis in an Immunocompetent Patient with Cyclic Vomiting Syndrome

Abstract

Herpes esophagitis (HE) is common in the immunosuppressed but has rarely been reported in the immunocompetent. A recent case series identified 56 cases of confirmed HE in immunocompetent hosts since 1950. Cyclic Vomiting Syndrome (CVS) is an idiopathic disorder characterized by chronically recurring, self-limited episodes of intense nausea and vomiting with a 2% prevalence in the pediatric population. Complications of acute episodes of CVS include dehydration, electrolyte imbalance, Mallory-Weiss tear, weight loss, and esophagitis. To our knowledge, there have been no reported cases of HE in an immunocompetent patient with a history of CVS until now. 19-year-old male with past medical history of depression and 5 year history of nausea and vomiting, which had recently been diagnosed as CVS after extensive workup. He had been released from the hospital 3 days ago for intractable nausea and vomiting, but presented again to the ED with multiple episodes of vomiting. In the ED he complained of new pleuritic chest pain and tightness. Examination revealed pleural rub. Labs revealed a WBC count of 22.4, a creatinine of 1.4, and a UDS positive for THC. Chest x-ray showed pneumopericardium and pneumomediastinum. Follow-up CT chest confirmed esophageal perforation. He was immediately taken for an EGD, which showed no tear or perforation suggesting that occult perforation had sealed spontaneously. EGD did reveal new ulcerations in the distal third of the esophagus, which had not been seen on EGD in the previous workup of CVS. Biopsies obtained from the ulcers were positive for Herpes Simplex Virus. Subsequent testing for HIV and other sources of immunodeficiency were negative. He was then prescribed course of acyclovir, stabilized, and was discharged. HE is rarely reported in immunocompetent hosts, and has not been previously reported in patients with CVS. Young males are most often affected (male:female ratio 2.3:1) (mean age 35 +/- 18.8 years). HE most often presents with odynophagia, fever, chest pain, and dysphagia. Rarely, HE presents with nausea and vomiting. The disease is often self-limited. While esophagitis has been noted as a complication of CVS, we know of no prior reports of immunocompetent HE associated with CVS. This finding raises questions about the possible relationship between CVS and HE. CVS may predispose patients to infection. Alternatively, some presumed cases of CVS may in fact be rare presentations of HE.