Primary Herpes Simplex Virus-1 Infection Manifesting as Severe Esophagitis in an Adult Immunocompetent Host With Eosinophilic Esophagitis

Abstract

While a common cause for infectious esophagitis in the immunocompromised, primary herpes esophagitis rarely affects immunocompetent hosts. Meanwhile, incidence of eosinophilic esophagitis (EoE) has increased over the past several decades, with a majority of those affected being young males. Several cases have been reported in the pediatric population, but we describe a case of an immunocompetent adult with known EoE who presented with a primary herpes simplex virus 1 (HSV1) infection manifesting as severe esophagitis. A 20-year-old male with known EoE complicated by prior esophageal food impactions presented to the emergency department with severe odynophagia and solid food dysphagia. The diagnosis of EoE was based on esophageal biopsies showing greater than 50 eosinophils per high powered field. He had been prescribed courses of swallowed aerosolized fluticasone in the past for symptomatic EoE, but had not required treatment in several years. The preceding week, he experienced fevers, chills, ear pain, pharyngitis, and a pustular lesion on his genitalia. He reported difficulty maintaining oral intake, and was found to have a mild leukocytosis. EGD was performed which showed multiple nonbleeding medium sized punched-out ulcers in the mid and distal esophagus. Biopsies of ulcer periphery demonstrated viral cytopathic effect and confirmed HSV by immunohistochemical staining. Histology also confirmed presence of eosinophils, up to 6 per high powered field. The patient was treated with a course of acyclovir with subsequent resolution of his symptoms. Initial HSV serologies were negative, but repeat testing several weeks later showed HSV seroconversion (HSV-1 IgG: 9.08). The patient tested negative for HIV and other sexually transmitted infections. This case adds to the few, but growing number of young immunocompetent hosts with EoE who present with primary HSV esophagitis. One potential reason why such patients are at risk for infectious esophagitis is the need for topical steroid therapy, but as illustrated above, our patient had not been on this treatment for many years. Rather, perhaps the impaired esophageal mucosal integrity present in EoE allows for increased susceptibility to HSV infection at this location. Recognition of this association allows for earlier detection and more targeted treatment.1773_A Figure 1. Severe HSV esophagitis, distal esophagus.1773_B Figure 2. HSV ulcers, mid esophagus.