Atypical Presentation of Herpes Simplex Esophagitis on EGD in an Immunocompetent Patient

Abstract

Purpose: We present a case of HSE in a 21 year old male who came to the ER with epigastric pain and odynophagia. Past medical history was significant for asthma without use of inhaled or oral steroid therapy. Clinical exam was unremarkable. CBC, BMP and CT scan of abdomen were normal. Patient had an EGD which showed diffuse white plaques throughout the esophagus and ulcerations in distal esophagus. Brushings and biopsy was done and patient was started on Diflucan® with working diagnosis of esophageal Candidiasis. HIV test came back negative. Biopsy results showed Herpes Simplex esophagitis, CMV titers and fungal stain were negative. Patient symptoms later resolved on acyclovir. Conclusion: HSE is a rare in Immunocompetant patients with only a few case reports in literature. This could be because of asymptomatic and self limiting clinical course of HSE. The majority of symptomatic immunocompetent patients with HSE will present with acute onset of esophageal complaints but a subset of patients will present with odynophagia and fever. Other complaints include chest pain, heartburn, dysphagia and poor oral intake. HSE has a distinct endoscopic appearance. Early stages have vesicles which later slough to become discrete, circumscribed ulcers with raised edges. These lesions have punched-out or volcano like appearance and cobble stoning can be seen due to clustering. Later exudates and necrosis can be seen. We present a case in which HSE manifests in a normal host with atypical features. EGD showed diffuse white plaques throughout the esophagus with ulcerations in the distal esophagus. The findings of white plaques throughout the esophagus were suggestive of candidal esophagitis and the patient was initially treated with Diflucan®. Multiple brushings and biopsies were taken from esophagus which revealed histological features of HSE. Both stain for fungi and CMV test were negative. Patient was later started on acyclovir with resolution of symptoms. This case presents HSE mimicking candidal esophagitis and underlines the importance of biopsy during EGD for definitive diagnosis. High suspicion for HSE is warranted in young patients who present with severe odynophagia irrespective of their risk factors.