Herpetic oesophagitis in an immunocompetent infant with gastroesophageal reflux

Abstract

A 7-month-old boy presented to our emergency department because of persistent vomiting with streaks of blood despite esomeprazole treatment for gastroesophageal reflux for 3 months. Additionally, he refused solid food and showed failure to thrive (decrease of two standard deviation scores for weight-for-age). The boy's mother was known to have recurrent herpes labialis. Abdominal ultrasound showed no pyloric hypertrophy, but a barium swallow radiogram revealed a dilated distal oesophagus with a pinpoint stenosis (figure A). Oesophagogastroscopy showed extensive inflammation with whitish exudate and friable mucosa of the distal part of the oesophagus (figure B; video), as well as stenosis of the lower oesophageal sphincter. During oesophagogastroscopy, the stenosis was dilated to 8 mm and multiple biopsies were taken. Histopathological examination revealed features typical for herpes simplex virus oesophagitis (HSVE; figure C), which was confirmed by herpes simplex virus (HSV) immunohistochemistry (figure D). Moreover, HSV-1 was detected by PCR analysis. Additional laboratory tests revealed normal levels of T, B, and NK lymphocyte subpopulations and immunoglobulins. The patient was treated with valaciclovir (30 mg/kg per day in two doses) for 10 days, high-dose omeprazole (2 mg/kg per day in one dose), and nasogastric tube feeding. 2 weeks after initiation of treatment, the patient was symptom free and gained weight. 4 weeks after valaciclovir treatment, oesophagogastroscopy showed remarkable improvement with complete disappearance of mucosal inflammation, but clearly visible was a mild sliding hiatal hernia. Nasogastric tube feeding was discontinued after the endoscopy and omeprazole treatment was continued to treat reflux oesophagitis.