Herpes Simplex Esophagitis Presenting as Melena and Fungating Esophageal Mass in an Immunocompetent Patient

Abstract

Introduction: Herpes simplex esophagitis (HSE) usually presents as dysphagia and odynophagia and is mostly seen in immunocompromised patient with esophagogastrodeudonoscopy (EGD) showing circumscribed ulcers. Here we describe an interesting case of HSE presenting as melena and fungating esophageal mass in an immunocompetent patient. Case Report: A 83 year old woman with known hypertension, hyperlipidemia and idiopathic thrombocytopenic purpura (ITP) who underwent coronary artery bypass graft (CABG) surgery 9 days prior, presented with melena with hemoglobin of 8.4 gm/dl and platelet count of 163,000/μL. EGD showed a 9 mm x 8 mm fungating mass in the lower third of esophagus (Figure 1). Biopsy showed benign squamous epithelium with intranuclear inclusions highly suspicious for HSE. Patient was treated with acyclovir and high dose proton pump inhibitors (PPI) with rapid resolution of melena and was subsequently discharged. Discussion: HSE is a rare diagnosis in immunocompetent patients and is usually self limited. Most patients present with dysphagia and odynophagia. Presentation as gastro-intestinal (GI) bleed, even though has been reported, is very rare. EGD typically shows vesicles or punched out “volcano” ulcers. These are mostly located in the distal or mid esophagus as was the lesion in our patient; however, our patient had a fungating mass which is atypical. It is recommended to take biopsy from the edge of the lesion which shows characteristic multinucleated giant cells with eosinophilic intranuclear inclusions, called Cowdry type A intranuclear inclusions as was seen in our patient. Conclusion: HSE should be suspected as a cause of GI bleed especially if a lesion is noted in distal esophagus even when a patient is immunocompetent. Appropriate biopsies from the edges of the lesion should be taken to exclude the diagnosis.Figure: Esophagogastroduodenoscopy (EGD) showed a 9 mm x 8 mm fungating mass in the lower third of esophagus.