Pooja R. Patel, BS1, Antonios Wehbeh, MD1, Robert E. Emerson, MD2, Hala Fatima, MD3, Hak Nam Kim, MD4
1Indiana University School of Medicine, Indianapolis, IN; 2Indiana University Health, Indianapolis, IN; 3Indiana University Medical Center, Indianapolis, IN; 4Indiana University Hospital, Indianapolis, IN
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 Figure 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.
Citation: Pooja R. Patel, BS; Antonios Wehbeh, MD; Robert E. Emerson, MD; Hala Fatima, MD; Hak Nam Kim, MD. P0322 - ATYPICAL PRESENTATION OF HERPES SIMPLEX VIRUS ESOPHAGITIS IN AN IMMUNOCOMPETENT PATIENT. Program No. P0322. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.