Primary Herpes Esophagitis in a Liver Transplant Recipient

Abstract

Purpose: Herpes esophagitis is a common infection in immunocompromised patients. It is usually due to secondary reactivation, but it may also present as a primary infection. We present a case of primary infection of herpes simplex virus in a liver transplant recipient. Case: A 27-year-old woman with a history of liver transplant for autoimmune hepatitis-induced cirrhosis underwent a change of medication from tacrolimus to sirolimus, due to chronic kidney disease from a calcineurin inhibitor. Within one week, the patient developed fevers, myalgias, and odynophagia. Prior to transplant, she had negative testing for cytomegalovirus (CMV), IgG Ab, and herpes simplex virus (HSV) type 1 and 2 IgG Ab. Physical exam showed temperature of 102.3°F, multiple shallow ulcers on the tongue and posterior pharynx, and no hepatosplenomegaly or lymphadenopathy. Laboratory tests showed white blood cell count of 4,100 cells/mm3, hemoglobin 11.5 g/dL, hematocrit 35.7%, platelet count 167,000 cells/mm3, creatinine 1.85 mg/dL (baseline 1.5 mg/dL), sirolimus trough 5.7 μg/L and normal liver chemistries. CMV PCR, EBV PCR, and HIV Ab were negative. The ulcers from the oropharynx were sampled; cultures were positive for HSV. An upper endoscopy showed exudates at the gastroesophageal junction with no ulcers. Esophageal biopsies showed numerous HSV-infected squamous cells. HSV-associated erosive esophagitis was confirmed by immunostaining. Serum HSV-1 IgM Ab was positive, confirming a primary herpes infection causing esophagitis. HSV-2 IgM Ab was negative. The patient was started on acyclovir with improvement of her symptoms, and discharged home on valacyclovir. Discussion: The esophagus is the visceral organ most commonly affected by herpes, although it is not uncommon to have concurrent oral lesions. Herpes esophagitis is most commonly found in the immunocompromised patient, especially bone marrow and solid organ transplant patients. The vast majority of cases are caused by HSV-1. The typical findings found endoscopically are well-circumscribed ulcers that have a “volcano-like” appearance. However, exudates and plaques may be the only findings endoscopically. Biopsies and/or brushings should be taken from exudative areas and the edge of ulcers, where the virus that infects the squamous epithelium are most likely to be present. Oral acyclovir is recommended as therapy in the immunocompromised patient. If symptoms are severe, intravenous acyclovir may also be used. Viscous lidocaine provides only modest symptomatic benefit. Opportunistic infections, including HSV, should always be considered in immunocompromised patients who present with fever. This is particularly the case in patients with oral lesions or esophageal complaints.