Simple or Complex? A Not so Straightforward Manifestation of Herpes Simplex Virus

Abstract

Esophagitis presents with odynophagia and/or dysphagia and diagnosed based endoscopic ulcerations and biopsy pathology. Etiology for esophagitis is either noninfectious or infectious; noninfectious causes such as gastroesophageal reflux disease (GERD) are most common. Herpes simplex virus (HSV) esophagitis is a well described infectious cause in immunocompromised hosts, but rarely seen in immunocompetent individuals. This is a 28 year old male with no past medical history who presented to his PCP with a chief complaint of sore throat which was presumed to be benign. Eight weeks later he presented to urgent care with persistent sore throat, and started on amoxicillin for bacterial pharyngitis. The next day he was seen in the emergency department for fevers and odynophagia. He was started on pantoprazole for GERD and continued on amoxicillin. He was seen by gastroenterology five days later for further evaluation of odynophagia. He also reported severe heartburn, which improved slightly with pantoprazole, and inability to eat due to pain. He reported no prior surgeries, social alcohol use, and no pertinent family history. Physical exam revealed an enlarged left tonsil without exudate and lab work was unremarkable. On endoscopic evaluation he had LA grade D erosive esophagitis with circumferential severe ulcerations in the distal esophagus and scattered mid esophageal ulcerations. Biopsies of esophageal ulcerations showed rare multinucleated and nuclear viral inclusions and immunohistochemical stains were positive for HSV1 and HSV2, consistent with herpes simplex esophagitis. Additional lab work revealed an HSV1/2 IgM of 4.08, an HSV 1 IgG of >8.0, a negative HSV 2 IgG. He was noted to have a negative HIV test and a normal CD4 count. He was started on a Valtrex with rapid improvement of symptoms. Although HSV is an uncommon cause of esophagitis in immunocompetent hosts, it is an important differential in patients who do not respond to conservative therapy for a noninfectious cause. Herpes simplex esophagitis is usually self-limited in immunocompetent hosts, but can also manifest with significant esophageal ulceration and erosion, as shown in this case. Untreated herpes simplex esophagitis can result in weight loss and malnutrition due odynophagia, worsening of esophageal ulcerations, and even esophageal perforation. These patients respond well to antiviral therapy and early definitive diagnosis can lead to early treatment and improved patient outcomes.1741_A Figure 1. Distal esophagus with LA grade D erosive esophagitis and severe circumferential ulcerations1741_B Figure 2. Scattered ulcerations in the mid esophagus1741_C Figure 3. Multinucleated cell at single arrow; cells showing margination of chromatin at double arrows