HSV Esophagitis Masquerading as Candidiasis: Is Age to Blame?

Abstract

Esophageal candidiasis is a common infectious cause for patients presenting with dysphagia, especially if they are immunocompromised. Classic findings on EGD include scattered white plaques lining the esophageal mucosa. However, rarely these white plaques may also be seen in herpes simplex virus (HSV) esophagitis. This is a case of an 88-year-old female with dementia, HTN, and GERD presenting with symptoms of dysphagia. She received a recent EGD with endoscopic dilation two months prior without resolution. The patient had decreased oral intake associated with weight loss. She did not have any causes of immunodeficiency such as steroids, inhalers, history of HIV, or abnormal WBC. She underwent repeat EGD with findings of diffuse, linear, white, plaque-like lesions in the lower third of the esophagus suspicious for candidiasis. Brushings of the esophagus were obtained revealing cellular changes consistent with HSV. The patient was started on acyclovir with complete resolution of her dysphagia. Esophageal candidiasis is primarily seen in patients with impaired cell mediated immunity. The findings of white esophageal plaques was unexpected in this patient given she had no prior underlying immunodeficiency. The patient's age contributing to being biologically immunocompromised was a possible explanation; however, the cytology findings of HSV esophagitis were unanticipated. HSV esophagitis is common in immunocompromised, but very rare in immunocompetent patients with only small case series reported. HSV esophagitis typically presents with acute onset of dysphagia, associated with odynophagia, chest pain, and/or fevers. HSV may affect any part of the GI tract, but the esophagus is the most commonly affected. The most common finding on EGD is friable mucosa with discrete shallow ulcers. It is selflimiting in immunocompetent patients with conservative treatment approaches. However, given the severity of the patient's symptoms and suspicion of being biologically immunosuppressed due to her age, treatment was initiated. This case presents demonstrates that HSV esophagitis may present with atypical endoscopic findings, and that classic endoscopic findings for candidiasis should still prompt further analysis to establish a definite diagnosis. Additionally, it highlights that age must be considered as a potential cause for an immunosuppressed state, reinforcing that a broad differential diagnosis should be maintained in a patient presenting with dysphagia.1719_A Figure 1. Findings of diffuse linear, white, mucosal, plaquelike lesions in the lower third of the esophagus1719_B Figure 2. Findings of diffuse linear, white, mucosal, plaquelike lesions in the lower third of the esophagus1719_C Figure 3. Esophageal histology with margination of the nuclear chromatin, multinucleation and nuclear inclusions confirming diagnosis of herpes simplex virus