Herpes Esophagitis in an Immunocompetent Host

Abstract

Introduction: Esophagitis caused by HSV is well documented in immunocompromised patients. It is one of the AIDS defining illnesses however there are few cases documented in immunocompetent patients. Corticosteroids and chemotherapies are known risk factors for visceral herpes infections. Steroids are able to inhibit activation, proliferation and differentiation of all cells involved in mounting an immune response, such as T cells. Chemotherapy agents have immunosuppressive effects and cause loss of normal esophageal mucosal integrity, enhancing herpes reactivation. Most immunocompetent affected hosts experience odynophagia, fevers, respiratory symptoms, and dysphagia with anorexia. It generally affects the mid to distal part of the esophagus. In a symptomatic immunocompetent host, the symptoms should be self-resolving. In immunocompetent patients, herpes esophagitis may be a primary infection whereas in an immunocompromised patient, it may be a sign of reactivation of a latent infection. On endoscopy, herpes esophagitis presents as friable mucosa, numerous ulcers, and white exudates involving mid to distal esophagus. The diagnosis is based on endoscopic findings and confirmed by histopathological examination of the lesions, where it appears as ground glass nuclei and multinuclear giant cells. Acyclovir has shown improvement of symptoms in patients that are immunocompromised or immunocompetent. Case Report: 36-year-old female presented with complaints of dysphagia for 2 months. She reported gastroenteritis, fever and genital lesions prior. Her past medical history consisted of migraines and oral candidiasis. Methods: Physical was only significant for mild posterior pharyngeal erythema and moist mucous membranes. Labs were significant for negative HIV titers, positive HSV IgM, EBC IgG and CMV IgG. She underwent an EGD that revealed esophagitis typical of HSV in the middle third of the esophagus and multiple biopsies were taken. Results: All biopsies were negative for HSV. She was started on acyclovir, which led to symptom resolution. Discussion: In healthy patients, esophagitis occurs acutely and is self-limiting. The case presented is that of an immunocompetent patient with negative HIV titers and symptomatic dysphagia. Biopsies during EGD were still negative for HSV however the lesions seen on EGD were typical for HSV. Instead of being self-limited as has been described in other cases, her symptoms were relieved only after treatment with acyclovir.Figure 1