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Patel H, Nguyen SMT, Haque A, Krishnaswamy G. Odynophagia in a young adult: revisiting herpetic esophagitis and eosinophilic esophagitis. BMJ Case Rep 2022; 15:e251238. [PMID: 36368731 PMCID: PMC9660505 DOI: 10.1136/bcr-2022-251238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An immunocompetent man in his 20s presented with a 24-hour history of severe odynophagia, nausea, vomiting and throat pain. Esophagogastroduodenoscopy (EGD) revealed severe esophagitis with ulcerated mucosa, exudative debris, haemorrhage and multiple erosions. Biopsy of the oesophageal tissue demonstrated marginated chromatin, multinucleated giant cells and molding of nuclei, consistent with herpes simplex virus esophagitis (HSE). Treatment with oral acyclovir led to the complete resolution of symptoms. The patient subsequently developed dysphagia again, 8 months later. EGD showed furrowing and concentric rings typical of eosinophilic esophagitis (EoE), a diagnosis confirmed by biopsy. Treatment with a proton pump inhibitor and swallowed topical corticosteroids led to symptomatic improvement. Thus, HSE can occur in immunocompetent hosts and on occasion, HSE may be a harbinger of EoE, as evidenced by our extensive literature review. Mechanical disruption of the mucosal barrier by viruses, facilitating food allergen penetration, and associated immunological signaling abnormalities may be responsible phenomena requiring further elucidation.
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Affiliation(s)
- Hiral Patel
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Aaisha Haque
- Allergy, Asthma and Clinical Immunology, Salisbury VA Medical Center, Salisbury, North Carolina, USA
| | - Guha Krishnaswamy
- Allergy, Asthma and Clinical Immunology, Salisbury VA Medical Center, Salisbury, North Carolina, USA
- Department of Medicine, Section on Pulmonary, Critical Care, Allergy and Clinical Immunology, Section on Infectious Disease, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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A Patient with Eosinophilic Esophagitis and Herpes Simplex Esophagitis: A Case Report and Literature Review. Case Rep Gastrointest Med 2021; 2021:5519635. [PMID: 34123440 PMCID: PMC8169267 DOI: 10.1155/2021/5519635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/07/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Abstract
Acute herpes simplex esophagitis (HSE) is common in immunocompromised patients. Eosinophilic esophagitis (EoE) is characterized by immune-mediated eosinophil-predominant esophageal inflammation. We report a patient with human immunodeficiency virus infection who presented with dysphagia and odynophagia and was found to have HSE and EoE. The combination of these two relatively rare conditions suggests possible predisposition.
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Koutsoumourakis A, Gagalis A, Fotoulaki M, Stafylidou M. Rare Etiology of Odynophagia in a Female Adolescent. Case Rep Gastroenterol 2021; 15:352-358. [PMID: 33790725 PMCID: PMC7989787 DOI: 10.1159/000513801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/11/2020] [Indexed: 11/29/2022] Open
Abstract
Herpes esophagitis (HE) is a rare condition in immunocompetent adolescents. However, it commonly occurs as a primary infection in younger individuals. Herein, we report a 16-year-old female patient who had a history of fever for 5 days, odynophagia, and orolabial herpes infection for 7 days. Clusters of painful vesicles on an erythematous base on the lips, gingiva, and palate were observed on physical examination. Further, esophagogastroduodenoscopy revealed diffuse linear ulcerations in the distal esophagus. The patient then received the following treatment: intravenous (I.V.) acyclovir 5 mg/kg three times a day, I.V. omeprazole 40 mg two times a day, and acyclovir 5% cream four times a day. After 8 days of admission, the patient was discharged. A follow-up esophagogastroduodenoscopy was performed 7 weeks after discharge, and the results revealed that the esophageal mucosa had a normal appearance. The effect of antiviral treatment against HE remains unknown in these patients. Nevertheless, it is believed to accelerate the healing process in individuals with esophageal mucosal barrier damage. To the best of our knowledge, this case of a female adolescent with an intact immune system is the sixth case of herpes simplex esophagitis to be reported in the literature.
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Affiliation(s)
| | - Asterios Gagalis
- First Department of Internal Medicine, Papageorgiou Teaching Hospital, Thessaloniki, Greece
| | - Maria Fotoulaki
- Fourth Department of Pediatrics, Papageorgiou Teaching Hospital, Thessaloniki, Greece
| | - Maria Stafylidou
- First Department of Internal Medicine, Papageorgiou Teaching Hospital, Thessaloniki, Greece
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Rossetti D, Isoldi S, Oliva S. Eosinophilic Esophagitis: Update on Diagnosis and Treatment in Pediatric Patients. Paediatr Drugs 2020; 22:343-356. [PMID: 32519266 DOI: 10.1007/s40272-020-00398-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disorder characterized by symptomatic esophageal dysfunction and an eosinophil-predominant inflammation of the esophagus. EoE arises from interaction between genetic and environmental factors. In pediatric patients, clinical manifestations vary depending on age, from a gastroesophageal reflux disease (GERD)-like condition to severe dysphagic symptoms. Upper endoscopy is considered the gold standard for diagnosis and monitoring of EoE; however, significant efforts are underway to identify noninvasive diagnostic tools and biomarkers to avoid repetitive invasive procedures. Therapeutic first-line options currently available for EoE are elimination diets, proton pump inhibitors (PPIs), and steroids. The aim of treatment is to improve clinical symptoms while obtaining mucosal healing and avoiding long-term complications. Dietary treatment options comprise different empiric diets or an exclusively amino acid formula. Despite the efficacy of diets, compliance is often challenging. PPIs and topical steroids represent the main pharmacological options for EoE, and both can induce and maintain remission. Topical steroids have been reported as more effective, but data on long-term safety remain insufficient for both these and PPIs. Endoscopic dilations are currently reserved for severe untreated fibrostenotic disease unresponsive to medical therapies. Several biologic agents are available but not yet approved for EoE.
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Affiliation(s)
- Danilo Rossetti
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy
| | - Sara Isoldi
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy.
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Kim J, Lee K, Lee W. A Case of Eosinophilic Esophagitis Associated with Herpes Esophagitis in a Pediatric Patient. Clin Endosc 2019; 52:606-611. [PMID: 31311913 PMCID: PMC6900291 DOI: 10.5946/ce.2019.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 05/08/2019] [Indexed: 12/12/2022] Open
Abstract
Eosinophilic esophagitis is a rare disease in Asian countries, but its incidence is growing rapidly in Western countries. The main pathophysiology of eosinophilic esophagitis is esophageal epithelial barrier dysfunction; disruption of the esophageal epithelial barrier easily induces antigen sensitization to foods and aeroallergens, which leads to subsequent esophageal inflammation as a result of eosinophil recruitment. Here we report a case of an 11-year-old Korean boy who suffered from fever, odynophagia, dysphagia, and chest pain. His upper endoscopic findings showed longitudinal ulcers with a volcano-like appearance at the distal esophagus. Polymerase chain reaction test results and biopsy specimens were positive for herpes simplex virus type 1. He was treated with acyclovir and a proton pump inhibitor, but his follow-up endoscopy showed typical patterns of eosinophilic esophagitis, and the biopsy specimens were compatible with the diagnostic criteria for eosinophilic esophagitis. Therefore, we report a very rare case of eosinophilic esophagitis after herpes esophagitis in a Korean child with normal immunity.
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Affiliation(s)
- Jisun Kim
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
| | - Kunsong Lee
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
| | - Wonae Lee
- Department of Pathology, Dankook University College of Medicine, Cheonan, Korea
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Hoversten P, Kamboj AK, Katzka DA. Infections of the esophagus: an update on risk factors, diagnosis, and management. Dis Esophagus 2018; 31:5123414. [PMID: 30295751 DOI: 10.1093/dote/doy094] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/28/2018] [Indexed: 12/11/2022]
Abstract
Infectious esophagitis is a leading cause of esophagitis worldwide. While esophageal infections have traditionally been associated with immunocompromised patients, these disorders are becoming increasingly recognized in immunocompetent individuals. The three most common etiologies of infectious esophagitis are Candida, herpes simplex virus, and cytomegalovirus. Human papilloma virus infection can also involve the esophagus in the form of ulcerative lesions and papillomas. Less common etiologies include various other fungal, bacterial, and viral organisms. This review provides a comprehensive update on risk factors, diagnosis, and management of both common and less common infections of the esophagus.
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Affiliation(s)
- P Hoversten
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - A K Kamboj
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Herpes Simplex Virus Esophagitis in Immunocompetent Children: A Harbinger of Eosinophilic Esophagitis? J Pediatr Gastroenterol Nutr 2018; 66:609-613. [PMID: 28937540 DOI: 10.1097/mpg.0000000000001748] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Herpes simplex virus (HSV) is a common cause of infectious esophagitis. The aim of this retrospective study is to identify comorbid and predisposing conditions and sequelae of HSV esophagitis in immunocompetent children. We reviewed 16 cases of HSV esophagitis diagnosed from January 1982 to March 2016. Five patients were immunosuppressed, 11 were immunocompetent and included in the study. Three (27%) had no other significant medical history. Five patients (45%) had repeat biopsies following their HSV infection, which showed eosinophilic infiltrate consistent with current diagnostic criteria of eosinophilic esophagitis (EoE), one of whom had known EoE. Environmental allergies and/or asthma were present in 4 of 5 of these patients. Among the immunocompetent patients, EoE was a comorbidity in almost half, although biopsies at the time of HSV esophagitis did not show diagnostic features of EoE. Clinical follow-up is therefore warranted for immunocompetent children presenting with HSV esophagitis, particularly those with atopic conditions.
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First case report of oesophageal actinomycosis in a patient with active eosinophilic oesophagitis. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 40:404-406. [PMID: 27242158 DOI: 10.1016/j.gastrohep.2016.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/18/2016] [Accepted: 04/21/2016] [Indexed: 01/07/2023]
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Acute Herpes Simplex Viral Esophagitis Occurring in 5 Immunocompetent Individuals With Eosinophilic Esophagitis. ACG Case Rep J 2016; 3:165-8. [PMID: 27144193 PMCID: PMC4843145 DOI: 10.14309/crj.2016.38] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 01/15/2016] [Indexed: 12/18/2022] Open
Abstract
Herpes simplex esophagitis (HSE) is an acute, severe viral infection of the esophagus, rarely occurring in immunocompetent individuals. Eosinophilic esophagitis (EoE) is a rare immune-mediated esophageal disorder. We recently observed 5 severe HSE cases in diagnosed EoE patients. Four of the 5 patients had active, untreated EoE at the time of infection, so HSE is not likely a side effect of swallowed topical corticosteroids, the first-line medical treatment of EoE. However, this coincidence of these 2 rare conditions raises the question of a causal relationship between these 2 forms of esophagitis, and whether active EoE might predispose to HSE infection.
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Abstract
PURPOSE OF REVIEW Infectious esophagitis generally occurs in patients with impaired immunity. Although methods to suppress the immune system evolve, the potential infectious consequences are poorly understood. The purpose of this article is to review the risk factors, diagnosis, and treatment of infectious esophagitis. RECENT FINDINGS Minimal pediatric data, including a few case reports and series, involve infectious esophagitis. Esophageal infections are usually caused by the following microbes, in order starting with the most common: Candida albicans, herpes simplex virus, and cytomegalovirus. Uncommon risk factors in these and other reports include epidural triamcinolone and oral budesonide in addition to more common risk factors such as HIV infection, chemotherapeutic agents, and transplant immunosuppressive medications. Rare reports involve immunocompetent patients and treatment of these patients is controversial. SUMMARY Understanding of infectious esophagitis is growing, and risk factors, diagnosis, and treatments are evolving.
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Molina-Infante J, Lucendo AJ. Update on topical steroid therapy for eosinophilic esophagitis. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:388-97. [PMID: 25630928 DOI: 10.1016/j.gastrohep.2014.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/13/2014] [Accepted: 12/18/2014] [Indexed: 01/07/2023]
Abstract
This review aims to summarize evolving evidence on topical steroid (TS) therapy for eosinophilic esophagitis (EoE). Currently, we still use "off-label" TS, originally designed for bronchial or intranasal delivery. Direct oral administration (i.e., oral viscous budesonide) achieves better histological results than the aerosolized swallowed route, due to longer mucosal contact time. High-dose fluticasone (880 μg bid) has recently shown higher cure rates in children and adults. Steroid resistance is present in around 25-40% of patients. Nonetheless, novel steroid formulations specifically designed for EoE have exhibited outstanding preliminary results (cure rates around 100%). Narrow caliber esophagus (<13 mm) might explain persistent dysphagia despite histological remission on TS therapy and endoscopic dilation should be considered. TS are currently considered safe drugs, but we lack long-term safety data. Maintenance anti-inflammatory therapy is recommended in all patients to prevent disease recurrence and esophageal fibrotic remodeling, although this strategy is yet to be defined.
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Affiliation(s)
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
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