Hematemesis Due to Severe HSV Esophagitis: A Rare Occurrence in Immunocompetent Patients

Abstract

Purpose: To include HSV esophagitis in the differential diagnosis of non-cirrhotic patients presenting with hematemesis. A 69-year-old man with past medical history of coronary artery disease, Fournier's gangrene treated surgically, diabetes mellitus II and heartburn presented to the emergency room with nausea and vomiting. While in the ER, he started to have hematemesis with hemoglobin dropping from 13.9 gm/dl to 9.4 gm/dl overnight. A nasogastric tube drained a large amount of bright red blood. He had tachycardia but his blood pressure remained stable. He was given intravenous fluids, blood products and proton pump inhibitors. An esophagogastroduodenoscopy (EGD) showed severe erosive esophagitis involving 50-75% of the esophageal mucosa. The ulcerated mucosa was covered with whitish exudates and clotted blood, consistent with a recent bleed. Esophageal biopsies showed cytopathic changes and immunohistochemical staining of esophageal biopsies was positive for HSV. No evidence of a fungal infection was found. The patient was started on acyclovir. He did not have recurrent hematemesis and was discharged home after a few days. Herpes simplex esophagitis (HSV-E) is usually caused by HSV 1. It has been described in case reports and is considered to be rare in immunocompetent patients. In patients less than 40 years old, 77% of the patients with HSV-E are men, but sex distribution is equal in older patients. Presenting complaints usually include odynophagia, dysphagia, fever, epigastric pain, nausea and vomiting. Fistula formation, food impaction and hemorrhage are among the rare complications of HSV-E. Although a barium swallow can show non-specific ulcer(s) in the esophagus, the diagnosis is usually established with EGD and biopsies/brushings that should be obtained from the edges of the ulcer where viral cytopathic effect is most likely to be present. Histological findings of multinucleated giant cells with ground glass nuclei and eosinophilic inclusions, and immunohistochemistry are helpful in establishing the diagnosis. HSV DNA polymerase chain reaction is considered to be the most sensitive test. Although HSV-E is considered to be a self limiting condition in immunocompetent patients, the treatment with acyclovir hastens the recovery and shortens the illness and is recommended in patient with complications. Recurrent disease is considered to be very rare. Conclusion: HSV-E is a rare condition among immunocompetent patients that can cause life- threatening complications. Thus, it should be included in the differential diagnosis while working up a patient presenting with various upper gastrointestinal and esophageal symptoms, including hematemesis.