A Rare Case of Primary Herpes Esophagitis in an Immunocompetent Young Adult

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Introduction Herpes Simplex Viral (HSV) esophagitis is an opportunistic infection that is seen in patients with impaired immunity. It is rarely seen in immunocompetent individuals. It may result from direct spread to the esophagus from an oro-pharyngeal infection or can occur in patients with latent HSV by reactivation of the virus and dissemination to the esophageal mucosa via the vagus nerve. A few cases of HSV in immunocompetent individuals have been reported. We present a case of primary HSV esophagitis in an immunocompetent young adult whose biopsy was positive for both HSV 1 & 2. Clinical Vignette A 21 y/o male presented to the ED with complaints of sore throat, odynophagia and chest pain. Symptoms started as low grade fevers and viral-like illness and then progressed to throat soreness followed by severe odynophagia. Other symptoms included nausea, vomiting, subjective fevers, abdominal pain with radiation to the back during swallowing. Patient had no known past medical history, no history of cold sores and endorsed heterosexual activity with approximately twenty lifetime sexual partners and denied use of barrier contraception or engaging in oral sex. Physical examination was remarkable tonsillar erythema and edema, with mild pharyngeal erythema & exudates on tonsils. Blood tests were remarkable for positive HSV 1 &2 IgM and negative for HIV, CMV & EBV. CT neck showed bilateral tonsillitis, thickening of the esophagus, no evidence for peritonsillar abscess. Upper endoscopy revealed esophagitis manifested as edema, erosion and friable mucosa with spontaneous bleed on contact. Biopsy and pathology results was positive for herpes virus 1 &2. Further work up for underlying immune deficiencies and autoimmune diseases was negative. Patient was treated with oral acyclovir for 7days with resolution of symptoms. Discussion Very few cases of HSV esophagitis in immunocompetent individuals have been reported. It is mostly seen in immunocompromised individuals such as HIV carriers, transplant recipients, people on immunosuppressive agents and those with cancer. Initial symptoms usually include a viral prodrome followed by sore throat with odynophagia. Other common manifestations are dysphagia, retrosternal chest pain, weight loss, fever, nausea and vomiting. It is diagnosed via endoscopic inspection and histopathology findings. Treatment is with acyclovir, famiciclovir or valaciclovir. Symptoms may resolve over time with symptomatic treatment.1709_A Figure 1. Endoscopic findings1709_B Figure 2. Histology of HSV infected cells1709_C Figure 3. Immunohistochemical staining showing HSV infected cells