Herpes Simplex Esophagitis Research Articles

Clinicopathological Study of Herpes Simplex Esophagitis in a Tertiary Centre in India

Introduction and objectives: Herpes Simplex Virus (HSV) is a common viral pathogen, known to cause symptomatic disease in the immunocompromised hosts; however, it may occur in healthy individuals as well. Among the varied manifestations of the disease, involving skin, central nervous system and gastrointestinal systems, HSV esophagitis is a less studied entity from the Indian perspective. The aim of the study is to compare clinical, histologic and serologic data of HSV esophagitis patients. Materials and methods: 27 cases, proved to have HSV esophagitis on endoscopic biopsy were included, and the pertinent clinical and serologic characteristics were studied. Results: We found a male preponderance (p<0.01), which has been a well-established risk factor. Other risk factors are retroviral coinfection, Type 2 Diabetes Mellitus, immunosuppression, chemoradiation etc. among others. Eleven patients had retroviral coinfection, with CD4 counts of > 200/μL in all. Anti HSV 1 IgM antibody was most commonly detected on serology. HSV esophagitis affects immunocompromised patients more often than immunocompetent ones. Odynophagia and dysphagia are the most common symptoms. Histological evaluation for the characteristic inclusions helps in early diagnosis. The novelty of this study rests on the clinicopathological and serologic correlation, for a better understanding of the disease process, to prompt future large scale studies on the same. Conclusion: Herpes simplex esophagitis is most seen in immunocompromised patients. Apart from retroviral illness, other risk factors include diabetes mellitus, patients undergoing chemotherapy and other malignancy. CD4 counts in our series was >200/μL, in contrast to the cutoff of <200/μL described in literature.

Dysphagia and chest pain in a 7-year-old girl.

Dysphagia is a common gastrointestinal complaint in the pediatric population and should raise concern for oropharyngeal as well as esophageal disorders. We describe a 7-year old patient who was admitted to the hospital for sudden onset dysphagia, abdominal pain, and decreased oral intake. Extensive evaluations including endoscopy eventually revealed herpes simplex esophagitis as well as eosinophilic esophagitis. Herpes simplex esophagitis is a rare condition in the immunocompetent population and is typically self-resolving. Eosinophilic esophagitis is a chronic, inflammatory condition characterized by esophageal eosinophilia and signs of esophageal dysfunction. The concurrent presentation of both conditions in the pediatric population has rarely been described.

Viral esophagitis in non-human immunodeficiency virus patients: a case-control study.

Esophagitis, inflammation of the esophagus, can result from various causes, including reflux, infections, food allergies, medications, and trauma. Infectious esophagitis is the third most common cause after gastroesophageal reflux disease (GERD) and eosinophilic esophagitis worldwide. The primary causes of infectious esophagitis are candida esophagitis and viral esophagitis (VE) caused by herpes simplex virus (HSV) or cytomegalovirus (CMV). VE is typically associated with immunosuppression, with risk factors such as malignancy, chemotherapy, organ transplant, and human immunodeficiency virus (HIV). Infectious esophagitis is prevalent in about one-third of untreated acquired immunodeficiency syndrome (AIDS) patients, but recent reports indicate an increase in VE cases among immunocompetent individuals. This study aims to explore risk factors and patient demographics in non-HIV individuals. A case-control study that included patients 18 years and older diagnosed with HSV or CMV esophagitis who were identified through histopathologic examination or immunohistochemical staining. Cases were obtained by searching pathology reports between 2009-2022 from five MedStar Health Hospitals in the District of Columbia and Maryland. Controls were selected based on International Classification of Diseases (ICD) codes for esophagogastroduodenoscopy (EGD) with negative VE results within the same period. Patient demographics, comorbidities, laboratory parameters, endoscopic findings, and potential risk factors were collected through chart review. Out of 40,224 cases between 2009-2022, 50 cases of VE were identified, with 30 cases attributed to HSV, 19 cases to CMV, and one case of HSV/CMV coinfection. Hematemesis was the predominant symptom in patients with HSV (33%), while dysphagia was more prevalent in CMV patients (42%). The most common finding during EGD was ulceration in HSV patients (67%) and esophagitis in CMV patients (37%). Patients with VE had a higher likelihood of a history of immunosuppressive therapy, organ transplant, active malignancy, and systemic steroid use. However, a significant portion (34%) had no identifiable risk factors. The study's findings contribute to a better understanding of the clinical characteristics and risk factors associated with VE in non-HIV patients. The identification of immunosuppression and specific risk factors can aid in early detection, appropriate management, and targeted interventions for VE. Further research is warranted to explore the rising incidence of VE in immunocompetent individuals and to optimize preventive strategies and treatment approaches for this condition.

S2350 Mind the Steroids: Herpes Esophagitis in an Immunocompetent Patient After Steroid Therapy

Introduction: Infective esophagitis (IE) is rare, but well known to complicate the immunosuppressed state; particularly the HIV infected, transplant recipient, cancer patient and those treated with chronic corticosteroids or immunomodulators. Common infections include candida, cytomegalovirus, and herpes simplex virus (HSV). Steroids have been used for symptomatic relief of an acute sore throat. Short courses are considered benign with low risk of infectious complications. We report an immunocompetent patient found to have herpes esophagitis after a short course of corticosteroids. Case Description/Methods: A 41-year-old African American male with history of hypertension presented with worsening sore throat and odynophagia restricting oral intake. Prior to presentation, he had a 10-day history of sore throat. He was diagnosed with streptococcal pharyngitis and was on antibiotics and steroids 7 days ago. Given persistent symptoms he underwent laryngoscopy which demonstrated bilateral tonsillar exudates and normal pharyngeal mucosa, prompting admission and initiation of IV antibiotics and dexamethasone. He had modest improvement of pain, however 8 days later expressed worsening burning retrosternal chest pain and progressed oral intolerance. He underwent upper endoscopy revealing multiple circumferential erosions and Los Angeles grade D esophagitis of the lower third of the esophagus (Figure A). Biopsies demonstrated viral intranuclear inclusions that stained positive for HSV1/HSV2 (Figure B, C). His symptoms abated while on IV acyclovir allowing transition to oral valacyclovir. Discussion: Corticosteroids are well known for their anti-inflammatory effect but immunosuppression with short courses may be underestimated. Infectious sequalae such as herpetic esophagitis may complicate steroid use even when therapy duration is short. This patient was found to have progressive odynophagia while on corticosteroids administered for analgesia and had significant improvement after antiviral therapy. It is easy to overlook IE as a cause of odynophagia in the immunocompetent, however, with history of steroid use, a diagnosis of IE, especially HSV esophagitis, should be considered in the differential. Therefore, one should have a low threshold for early endoscopy when evaluating these patients.Figure 1.: A: Endoscopic photograph displaying multiple circumferential erosions and Los Angeles grade D esophagitis of the lower third of the esophagus. B: (x200): Photomicrograph of hematoxylin and eosin-stained section of the esophageal biopsy, showing multiple multinucleated epithelial cells. Cowdry type A is observed. C: (x200): IHC study using antibodies against HSV-1. Numerous intranuclear viral inclusions are positive with HSV-1 within the infected cells.

S2261 Vape-Induced Herpes Simplex Esophagitis in an Immunocompetent Host

S2261 Vape-Induced Herpes Simplex Esophagitis in an Immunocompetent Host

Efficacy Results of a Phase 2 Trial Evaluating Idelalisib Plus Ofatumumab in Patients with Previously Untreated Chronic Lymphocytic Leukemia

Efficacy Results of a Phase 2 Trial Evaluating Idelalisib Plus Ofatumumab in Patients with Previously Untreated Chronic Lymphocytic Leukemia

Herpes Simplex Virus Esophagitis in an Immunocompetent Patient with Upper Gastrointestinal Bleeding: A Case Report

Background: Herpes simplex virus (HSV) esophagitis is rarely seen in immunocompetent patients. Symptoms include odynophagia, dysphagia, fever, and/or extra-esophageal herpetic lesions. A male predominance is noted with individuals being inflicted with the illness in the third to fourth decade. Although HSV esophagitis has typical punch-out lesions on endoscopy, it is very similar in appearance to cytomegalovirus (CMV) and should be confirmed by tissue biopsy. Upper gastrointestinal bleeding is a rare complication of HSV esophagitis. Treatment of HSV esophagitis in immunocompetent patients is controversial.

Analytical Study of Diagnostic Role of Her2/Neu Expression In Gastroesophageal Lesions

Esophageal squamous cell carcinoma is one of the common types of malignant lesion and has its highest prevalence round the world. Though it is a common disorder, many of the patients only diagnose it in its advanced stage and these results in poor prognosis of the disease. In later stage, these lesions may severely develop in to lymph node metastasis and has more chances to spread across any of the vital organs. Barrett‟s esophagus, herpes simplex esophagitis, candidial esophagitis, leiomyoma, hyperplastic polyps are few of the benign and premalignant type of lesions. The advancement in endoscopy has opened many opportunities and diagnosis of all esophageal lesions became simple and effective. As the surgical procedures associated with the targeted therapy have become promising option for the treatment, many patients are being benefited out of technological advancement. The surplus of malignancies such as esophagus, esophago- gastric junction and stomach have become a significant health problem and threatening the people all over the world. Delayed diagnosis on these disorders particularly resulting in high mortality ratio and warrant for a systematic evaluation in patients. In this context, the present study analyse the association and prognostic significance of HER2/ neu in gastroesophageal lesions with other factors like age, size, histological type and grading and the incidence and distribution of gastroesophageal lesions in patients.

Machine learning approach for differentiating cytomegalovirus esophagitis from herpes simplex virus esophagitis

The endoscopic features between herpes simplex virus (HSV) and cytomegalovirus (CMV) esophagitis overlap significantly, and hence the differential diagnosis between HSV and CMV esophagitis is sometimes difficult. Therefore, we developed a machine-learning-based classifier to discriminate between CMV and HSV esophagitis. We analyzed 87 patients with HSV esophagitis and 63 patients with CMV esophagitis and developed a machine-learning-based artificial intelligence (AI) system using a total of 666 endoscopic images with HSV esophagitis and 416 endoscopic images with CMV esophagitis. In the five repeated five-fold cross-validations based on the hue–saturation–brightness color model, logistic regression with a least absolute shrinkage and selection operation showed the best performance (sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the receiver operating characteristic curve: 100%, 100%, 100%, 100%, 100%, and 1.0, respectively). Previous history of transplantation was included in classifiers as a clinical factor; the lower the performance of these classifiers, the greater the effect of including this clinical factor. Our machine-learning-based AI system for differential diagnosis between HSV and CMV esophagitis showed high accuracy, which could help clinicians with diagnoses.

HSV Esophagitis in an Immunocompetent 17-Year-Old

Herpes Simplex Virus (HSV) esophagitis is a relatively rare form of infectious esophagitis. Typically, patients with viral esophagitis are immunocompromised. HSV esophagitis in an immunocompetent patient is uncommonly reported. The objective of this case report is to discuss symptoms, investigations, imaging, and treatment of HSV esophagitis in a healthy adolescent male. A previously healthy 17-year-old male presented to the ED of our facility with a 5-day history of fever, odynophagia, lethargy, and 2 episodes of emesis that failed to resolve with antibiotic treatment. Investigations revealed a low platelet count, mild hyponatremia, hypochloremia, and an elevated AST and ALT. A respiratory infection panel as well as CMV IgG, HIV, Rickettsia, and EBV tests were negative. HSV-1 PCR was positive and upper endoscopy revealed a friable mucosa, erythema, and exudates in the lower esophagus and erythematous duodenopathy. The patient received a diagnosis of HSV esophagitis and was treated with a 14-day course of IV to PO acyclovir. There was a rapid improvement of his symptoms with antiviral therapy.

1732 Atypical Presentation of Herpes Simplex Virus Esophagitis in an Immunocompetent Patient

INTRODUCTION: Herpes Simplex Virus esophagitis (HSVE) is a well-documented opportunistic infection affecting immunocompromised patients. It can rarely manifest in the immunocompetent patient, with the most recent review in 2010 demonstrating 56 documented cases. Such patients commonly present with acute odynophagia, fever, and retrosternal pain. Here, we report a case of HSVE affecting an immunocompetent patient with a more subacute presentation. CASE DESCRIPTION/METHODS: A 37-year-old Nigerian female presented with generalized weakness, weight loss, and new onset dysphagia of two months duration. The dysphagia had progressed from solids to liquids with intermittent odynophagia. She denied fevers, chills, hematemesis, and melena. On exam, she was afebrile and exhibited no oropharyngeal lesions. Her abdomen was nontender to palpation and she demonstrated no hepatosplenomegaly or palpable masses. Labs showed severe iron deficiency anemia requiring transfusion, a normal white cell count, and a negative HIV screening test. An upper endoscopy (EGD) showed multiple small non-bleeding erosions throughout the middle and distal esophagus, as seen in Figures 1A and 1B respectively. Esophageal biopsy demonstrated squamous epithelium with viral inclusions and multinucleated cells. As demonstrated in Figure 2, immunohistochemical stain was focally positive for HSV supporting the diagnosis of herpes esophagitis. She was subsequently started on 7-day treatment of oral acyclovir 400 mg three times a day and had resolving symptoms one week later at her primary care visit. DISCUSSION: This case illustrates the importance of considering a diagnosis of HSVE in immunocompetent individuals, who can present with a subacute course of worsening dysphagia without systemic symptoms. Moreover, as HSVE endoscopic lesions can vary in appearance and location, gastroenterologists should have a low threshold for biopsying atypical lesions in the immunocompetent. In a recent study comparing endoscopic features of HSVE in immunocompromised and immunocompetent patients, endoscopists were more likely to mention the possibility of viral esophagitis on the endoscopy report in patients that were immunocompromised. Although HSVE in the immunocompetent is typically a self -limited disease, treatment with oral acyclovir can result in resolution of symptoms within 1-2 weeks. The etiology of HSVE in the immunocompetent may represent a primary infection of traumatized esophageal mucosa or reactivation after a previous infection.

3081 Four Severe Adverse Events Within One Week in a Patient With Ulcerative Colitis in the Setting of Prolonged High-Dose Steroid Use

INTRODUCTION: Prolonged high-dose steroids are known to predispose patients to opportunistic infections and bowel perforation. Here we present a unique case with Inflammatory Bowel Disease (IBD) who within 6 weeks developed four high-dose prednisone-related complications, including clostridium difficile (C. Diff) and cytomegalovirus (CMV) colitis, herpes simplex virus esophagitis and lastly colonic perforation. This case highlights the challenges of steroid refractory ulcerative colitis and the importance of alternative medications like biologics when patients don't have an adequate response to intravenous steroids in order to prevent iatrogenic immunosuppression-related adverse events. CASE DESCRIPTION/METHODS: A 73-year-old male had a past medical history of pan-UC presented to his primary care provider with diarrhea; tests for infectious causes, including C. Diff and CMV, were negative and colonoscopy with biopsy specimens supported a diagnosis of severe UC. Patient was started on prednisone and mesalamine but presented to the ED 2 weeks later due to ongoing symptoms. C. Diff was again ruled out and he was discharge on same dose of prednisone and mesalamine. 2 weeks later he was hospitalized for worsening abdominal pain, diarrhea and weight loss. Stool testing for C. Diff was positive so he was switched to intravenous methylprednisolone and oral vancomycin. During this time he was also found to have biopsy proven CMV colitis and HSV esophagitis. Despite treating him with ganciclovir, the patient remained symptomatic; CT was obtained which revealed free air due to a sigmoid perforation. The patient underwent a total abdominal colectomy with ileostomy. His post-operative course was unremarkable is currently off all immunosuppressive therapy, h as an ileostomy and overall is doing well. DISCUSSION: UC refractory to high dose steroid treatment is evident within one week after initiation of treatment. At that time, a change in treatment needs to be made and biologics should be considered in patients not responding to steroids. Our patient initially had negative serum (CMV) and stool (C. Diff) tests which led to ongoing steroid use. CMV typically develops after four or more weeks of severe immunosuppression. Herpes can flare up in anybody who is deeply immunosuppressed and colonic perforation – if associated with high-dose steroids – typically occurs also after four or more weeks of treatment. Our case illustrates that high-dose steroids can cause many complications within a short duration in a single patient.

2517 Isn't Herpes Esophagitis Enough?

INTRODUCTION: Herpes simplex (HSV) esophagitis, typically found in immunocompromised hosts, is increasingly being seen in immunocompetent hosts. A PubMed search covering the last 10 years yielded 8 publications of HSV esophagitis in the immunocompetent pediatric population, 3 of which were associated with eosinophilic esophagitis. No literature was found regarding HSV esophagitis associated with H. pylori infection. This is not surprising as the incidence of H. pylori is <10% in developed countries. To our knowledge, this is the first case report of co-infection of HSV esophagitis and H. pylori gastritis. CASE DESCRIPTION/METHODS: A healthy 16 year old male presented with 7 days of fever, severe odynophagia, and epigastric pain with no oral ulcers. He had a one year history of heartburn and dysphagia. Family history positive for H. pylori in paternal grandmother. He was seen at multiple facilities prior to transfer with prior diagnosis of costochondritis, pericarditis, pneumonia, and cholecystitis. Work up showed a normal KUB, abdominal ultrasound and upper GI series. WBC was 12.7 × 103/µL with left shift and elevated CRP at 86 mg/L. He was unresponsive to 24 hours of IV acid suppression therapy. Urgent endoscopy revealed extensive shallow ulcerations with exudate of the mid and distal esophagus and mild nodularity of the antrum. Empiric IV acyclovir was started with rapid symptom improvement within 24 hours. Biopsies showed ulcerated squamous esophageal mucosa with acute inflammation and exudate without eosinophilia. Adjacent reactive epithelium included binucleated to multinucleated cells with eosinophil nuclear structures suggestive of Cowdry type A inclusion bodies. A single cell showed a Cowdry type B inclusion but without the presence of classic multinucleated cells with molded nuclei. Immunohistochemistry confirmed the presence of HSV and was negative for CMV. Gastric biopsy showed mild, diffuse chronic gastritis with scant acute inflammation. CLO test was negative, but Diff-Quik and immunohistochemistry stains confirmed H. pylori. Triple therapy for H. pylori and a 10 day acyclovir course were completed. Currently his immune work-up is still pending. DISCUSSION: Since herpes esophagitis is a rare diagnosis in pediatrics, it is easy to ignore the possibility of co-infection. The importance of considering a co-infection in acute herpes esophagitis important to consider as the acute symptoms did not explain the patient's chronic peptic symptoms.

Toll-like receptor 3 (TLR3) variant and NLRP12 mutation confer susceptibility to a complex clinical presentation

Genetic aberrations in the toll-like receptor (TLR)3 pathway are associated with increased susceptibility to herpes simplex virus (HSV) infections. Leucine-rich repeat and PYD-containing protein (NLRP)12 is a component of the inflammasome apparatus, which is critical to an immediate innate inflammatory response. Aberrations in NLRP12 have been shown to mediate auto-inflammation. In this study, we present a 44-year old patient with severe HSV esophagitis and Crohn's disease. An immune and genetic investigation confirmed two coinciding genetic mutations in TLR3 and NLRP12. Our findings support conducting laboratory workup that targets TLR3 pathway in the immunocompetent host developing recurrent HSV infections.

Can endoscopists differentiate cytomegalovirus esophagitis from herpes simplex virus esophagitis based on gross endoscopic findings?

Differential diagnosis between herpes simplex virus (HSV) esophagitis and cytomegalovirus (CMV) esophagitis is challenging because there are many similarities and overlaps between their endoscopic features. The aims of this study were to investigate the implications of the endoscopic findings for the diagnosis of HSV and CMV esophagitis, and to develop a predictive model for differentiating CMV esophagitis from HSV esophagitis.Patients who underwent endoscopic examination and had pathologically-confirmed HSV or CMV esophagitis were eligible. Clinical characteristics and endoscopic features were retrospectively reviewed and categorized. A predictive model was developed based on parameters identified by logistic regression analysis.During the 8-year study period, HSV and CMV esophagitis were diagnosed in 85 and 63 patients, respectively. The endoscopic features of esophagitis were categorized and scored as follows: category 1 (-3 points): discrete ulcers or ulcers with vesicles, bullae, or pseudomembranes, category 2 (-2 points): coalescent or geographic ulcers, category 3 (1 points): ulcers with an uneven base, friability, or with a circumferential distribution, category 4 (2 points): punched-out, serpiginous, or healing ulcers with yellowish exudates. And previous history of transplantation (2 point) was included in the model as a discriminating clinical feature. The optimal cutoff point of the prediction model was 0 (area under receiver operating characteristic curve: 0.967), with positive scores favoring CMV esophagitis. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 96.8%, 89.4%, 92.6%, 87.3%, and 97.5%, respectively.The predictive model based on endoscopic and clinical findings appears to be accurate and useful in differentiating CMV esophagitis from HSV esophagitis.

Chest Pain in a Renal Transplant Recipient due to Concomitant Cytomegalovirus and Herpes Simplex Virus Esophagitis

Chest Pain in a Renal Transplant Recipient due to Concomitant Cytomegalovirus and Herpes Simplex Virus Esophagitis

HSV Esophagitis Masquerading as Candidiasis: Is Age to Blame?

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

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

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

Delicacy to Disaster: A Tale of Odynophagia

Herpes simplex esophagitis (HSE) is typically seen in patients with HIV, undergoing chemotherapy, or otherwise immunosuppressed. However, HSV may rarely cause esophagitis in immunocompetent patients, and is likely underdiagnosed as it is typically a self-limited process in this population and resolve spontaneously in one to two weeks. A 68-year-old male with history of peptic ulcer disease due to Helicobacter pylori, gastroesophageal and reflux disease presented to the emergency department after three days of acute onset severe odynophagia. His symptoms had begun suddenly while eating a spicy Cajun gumbo, after which he experienced intense burning pain with all oral intake, accompanied by nausea and vomiting. He denied constitutional symptoms, but recalled a mild sore throat and dry cough two days prior to onset of odynophagia, and two weeks previously had an oral “cold sore” which resolved spontaneously. The patient also endorsed a recent 10-pound weight loss, which he attributed to lifestyle modification. His vital signs, oropharyngeal exam, and abdominal exam were unremarkable, and no laboratory abnormalities were noted. Following initial symptomatic control with gastrointestinal cocktail, he underwent upper endoscopy. Multiple 3-5 mm, shallow, clean-based, irregular ulcerations were found in the distal and mid-esophagus, suggestive of herpes simplex esophagitis, and empiric valacyclovir was started given severity of his presenting symptoms. Biopsy revealed squamous mucosa ulceration with underlying granulation tissue. HSV-1 was subsequently identified in viral culture from esophageal biopsies, with corresponding positive HSV-1 IgG and IgM serology. Further infectious workup was unremarkable. His symptoms resolved entirely with a brief course of oral valacyclovir and he was tolerating a regular diet within a week. HSV is a rare cause of esophagitis in immunocompetent patients, and should prompt consideration of underlying immune deficiency. In this patient with a complex medical history, pill esophagitis, gastroesophageal reflux, or even malignancy would be much more likely causes of his acute odynophagia with alarm symptoms. Data regarding antiviral use in immunocompetent patients is sparse and the decision to treat is based on the severity of symptoms. This case illustrates the importance of keeping HSV in the differential for acute odynophagia regardless of immunologic status.

Variations in the Clinical Course of Patients With Herpes Simplex Virus Esophagitis Based on Immunocompetence and Presence Underlying Esophageal Disease

Introduction: Herpes simplex Virus (HSV) esophagitis is the second most common cause of infectious esophagitis and occurs in immunocompetent and immunocompromised patients. The aim of this study was to reappraise at the present time the clinical course of HSV esophagitis in different patient populations based on degree of immunocompetence and presence or absence of underlying esophageal disease. Methods: Cases of HSV esophagitis diagnosed from esophageal biopsy by expert gastrointestinal pathologists from 2006-2016 at a tertiary center were identified. Relevant demographic, clinical, and endoscopic data was extracted. Differences in clinical courses and outcomes were compared between immunocompromised and immunocompetent cohorts as well as between groups with and without underlying esophageal pathology. Immunocompromised patients had lymphopenia, leukopenia, malignancy, congenital or acquired immunodeficiencies or were on systemic immunosuppressive agents. Results: Forty-six patients with a mean age of 57.7 (+/- 19.2) years were included in the analysis. The most common presenting symptoms were odynophagia (34.8%) and dysphagia (30.4%). Twenty-nine (63%) of the patients were immunocompromised. Immunocompetent patients were more likely to experience persistent ulceration on repeat EGD (11.8% vs 0.0%, p=0.04). Immunosuppressed patients required extension of treatment duration at a greater rate than immunocompetent patients (42.1% vs 7.1%, p=0.02) and had longer duration of symptoms (49.7d vs 12.9d, p=-.04). Seventeen (37%) patients had underlying esophageal disease. Patients with esophageal disease were more likely to have concomitant esophageal candidiasis (41.2% vs 10.3%, p=0.01) and persistent ulceration on follow up EGD (11.8% vs 0.0%, p=0.04). Patients without esophageal disease were more likely to have ulceration in the proximal or middle third of the esophagus (72.4% vs 29.4%, p=0.004). There was no difference in presence of esophageal symptoms at time of last follow up between immunocompetent, immunocompromised, or either esophageal disease or no esophageal disease group. Conclusion: Nearly 40% of patients with HSV esophagitis are immunocompetent individuals and patients without underlying esophageal pathology. Immunocompetent patients and patients with underlying esophageal disease were more likely to experience ongoing ulceration on repeat EGD, but all groups of patients are unlikely to experience persistent esophageal symptoms following a primary infection.413_A Figure 1. Baseline demographic, clinical, endoscopic, and outcomes data for all 46 patients with HSV esophagitis.413_B Figure 2. Comparison of demographic, clinical, endoscopic, and outcomes data for immunocompetent versus immunocompromised patient populations.413_C Figure 3. Comparison of demographic, clinical, endoscopic, and outcomes data for patients without underlying esophageal disease versus patients with underlying esophageal disease.