Herpes esophagitis in healthy adults and adolescents: report of 3 cases and review of the literature

Herpes Simplex Virus Esophagitis in a Patient Receiving Long-Term Nasal Corticosteroids: A Rare Case

Herpetic esophagitis (HE), primarily caused by the herpes simplex virus (HSV)-1, is most commonly encountered in immunocompromised hosts, although it has been occasionally observed in immunocompetent patients. In the immunocompromised setting, it is typically correlated with human immunodeficiency virus (HIV) infection, malignancy, chemotherapy and radiotherapy, solid organ transplant, as well as the use of systemic corticosteroids and other immunosuppressive agents. We present the case of a 35-year-old patient on hemodialysis due to diabetic nephropathy who, after having received intranasal corticosteroids for three weeks, developed nausea, vomiting, and epigastric pain. Gastroscopy and subsequent biopsy revealed ulcerative esophagitis compatible with herpetic infection. Immunohistochemistry was negative for cytomegalovirus (CMV), while subsequent quantitative polymerase chain reaction (PCR) testing was positive for HSV-1, establishing the diagnosis of HSV esophagitis. After a 14-day course of valacyclovir, complete relief of symptoms was achieved. Herpetic esophagitis may occur in immunocompetent persons, whereas intranasal corticosteroids cannot be ruled out as potential contributors. Symptoms such as odynophagia, dysphagia, and fever in that setting warrant further investigation.

Herpetic esophagitis in healthy young adult

Herpetic esophagitis (HE) is common in immunocompromised patients but rarely reported in healthy young adults. A 28-year-old healthy male patient visited our clinic with a chief complaint of chest pain. An esophagogastroduodenoscopy revealed widely spread superficial multiple ulcers in the middle to the distal esophagus, and repeated biopsies from the ulcer were performed but revealed inconsistent findings with HE. Thus, he was clinically diagnosed with HE based on endoscopic findings and serologic tests of immunoglobulin M (IgM)/immunoglobulin G (IgG) for herpes simplex virus. He responded to valacyclovir, and all esophageal ulcers had scarred.

Herpes Simplex Virus Esophagitis in an Immunocompetent Patient

Esophagitis due to herpes simplex virus (HSV) infection is a rare entity in the immunocompetent population. It is usually seen in immunocompromised hosts, those with human immunodeficiency virus (HIV) infection, malignancies, and patients on immunosuppressive medications. We present a case of a young immunocompetent man with anabolic steroid use who presented with esophagitis symptoms found to be from HSV infection. So far, the use of corticosteroids has been reported as a predisposing factor for HSV esophagitis in immunocompetent hosts in multiple case reports. However, our case suspects that transient immunosuppression with similar medication can cause HSV esophagitis in otherwise immunocompetent hosts.

Herpetic Esophagitis: A Cause of Dysphagia in a Malnourished Patient

Herpetic esophagitis (HE) is an esophageal infection caused by herpes simplex virus (HSV). Although less common, it can occasionally affect immunocompetent hosts. It can manifest as odynophagia and/or dysphagia and should lead to an investigation by upper digestive endoscopy with a biopsy. The authors report a case of a 65-year-old man with a past medical history relevant for schizophrenia, oligophrenia, and malnutrition, and no other history or evidence of immunosuppression, who presented with severe dysphagia over weeks and recent episodes of food aspiration with consequent pneumonia. An upper gastrointestinal endoscopy was performed, revealing severe stenosis at the level of the gastroesophageal junction with scar tissue, not transposable with the endoscope. The biopsy led to the diagnosis of hepatic esophagitis. Despite the immunocompetent status (excepting only the risk factor malnutrition) and treatment with acyclovir, with initial clinical improvement, the patient died a few weeks after diagnosis after multiple respiratory complications such as nosocomial infection. This case highlights that herpetic esophagitis is sometimes observed in immunocompetent hosts. HE has a self-limited course, with severe complications more frequent in immunosuppressed patients. However, it is also important to suspect this condition in immunocompetent patients and look for risk factors, given the potential morbidity this disease entails. In this group of patients, the presence of predisposing factors and associated comorbidities, such as malnutrition, alcohol consumption, or use of corticosteroids, have been associated with the development of viral esophagitis (including HE). HE remains a clinical challenge, especially in patients with risk factors for immunosuppression, such as malnutrition, as in the reported case.

Prolonged Intractable Hiccups Associated with HSV (I&II) Esophagitis and H. pylori Gastritis

An immunocompetent male presented with an intractable hiccup. EGD revealed circumferential ulceration of middistal esophagus and biopsies confirmed HSV (I&II) esophagitis and H. pylori gastritis. He was prescribed triple therapy for H. pylori and acyclovir for HSV esophagitis. HSV esophagitis and H. pylori should be included in differential for intractable hiccups.

Odynophagia in a young adult: revisiting herpetic esophagitis and eosinophilic esophagitis

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.

Iron-deficiency anemia following herpetic esophagitis in a previously healthy female

Introduction

Herpetic Esophagitis is caused by the Herpes Simplex virus, which generally affects immunocompromised individuals and is rarely seen in healthy individuals. Symptoms are usually self-limiting.

Case presentation

We report the case of a 68-year-old female who presented with odynophagia, dysphagia, and epigastric pain with no other underlying disease. Endoscopic findings of soft, nodular, and friable growths just above the squamocolumnar junction with diffuse ulcerations in the distal esophagus, led to the diagnosis. It was confirmed with a histopathological report which revealed multinucleated giant cells with eosinophilic intranuclear inclusions. During follow-up, laboratory investigations revealed iron deficiency anemia, which was the consequence of GI bleeding.

Clinical discussion

Herpes Simplex virus esophagitis can occur in immunocompetent individuals and even it can cause food impaction and GI bleeding, which can lead to Iron deficiency anemia.

Conclusion

Hence, follow-up of patients is important for early diagnosis and intervention of any complications that may arise.

Herpes Simplex Virus Esophagitis as a Presentation of Febrile Neutropenia: A Case Report

Herpes Simplex Virus esophagitis typically manifests as mucocutaneous lesions in immunocompromised patients, most frequently in organ and bone marrow transplant recipients. However, it has not been appropriately reported as a cause of febrile neutropenia despite being a relatively common opportunistic infection in this patient population.  A 58-year-old man recently diagnosed with Ewing Sarcoma for which he was receiving chemotherapy presented with febrile neutropenia. Following a prolonged hospital course characterized by persistent fevers, an endoscopic evaluation was performed and diagnosis of Herpes Simplex Virus esophagitis was confirmed via histopathology. Prompt administration of acyclovir resulted in the complete resolution of the patient's symptoms.  Recognition of Herpes Simplex Virus esophagitis as an etiology of febrile neutropenia can ensure more prompt diagnosis and allow for appropriate management of these patients. In addition, this case report emphasizes a need for further research into additional diagnostic markers in the workup of these patients and the incorporation of antiviral therapy in febrile neutropenia algorithms.

Infectious Esophagitis in Children

Infectious esophagitis is the third most common cause of esophagitis after gastroesophageal reflux disease and eosinophilic esophagitis (EoE) and should always be considered in the differential of patients with dysphagia and odynophagia. The most common organisms causing disease are candida, Herpes simplex virus (HSV) and cytomegalovirus (CMV). It is well recognized that an impaired local or systemic immune system is a risk factor for disease; however, esophageal dysmotility and disruptions in esophageal homeostasis and the esophageal milieu are likely to represent additional risk factors in disease pathogenesis.

A Rare Case of Herpes Esophagitis in an Immunocompetent Elderly Patient

Herpes esophagitis is common among immunocompromised hosts but is relatively rare among immunocompetent patients. Its symptoms are vague because many different symptoms can be induced by esophageal lesions. Here, we report a case of herpes esophagitis in an elderly immunocompetent patient. A 91-year-old woman visited our community hospital with a complaint of appetite loss for several days. Although she did not have any symptoms of epigastric, oral, or retrosternal pain, multiple ulcers were detected in her esophagus. Biopsy of the edge of the ulcer showed giant cells, indicating a herpes virus infection. She was diagnosed with herpes esophagitis and treated with acyclovir for one week. Her symptoms completely resolved after treatment, and she was discharged. Herpes esophagitis can manifest as vague symptoms in immunocompetent elderly patients. Therefore, herpes esophagitis must be considered in the differential diagnosis of elderly patients presenting with vague symptoms.

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.

Herpes simplex esophagitis in an immunocompetent host: a case report

Esophagitis caused by Herpes Simplex virus is a well-recognized opportunistic infection in the immunocompromised or severely ill host. However, it is uncommon in otherwise immunocompetent host. It usually responds well to a course of acyclovir. We report a case of young female without any other immunocompromised state who presented with severe dysphagia. She was diagnosed endoscopically and later with histopathology and recovered well after a course of acyclovir.

Endoscopic tissue sampling - Part 1: Upper gastrointestinal and hepatopancreatobiliary tracts. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends that, where there is a suspicion of eosinophilic esophagitis, at least six biopsies should be taken, two to four biopsies from the distal esophagus and two to four biopsies from the proximal esophagus, targeting areas with endoscopic mucosal abnormalities. Distal and proximal biopsies should be placed in separate containers.Strong recommendation, low quality of evidence. 2: ESGE recommends obtaining six biopsies, including from the base and edge of the esophageal ulcers, for histologic analysis in patients with suspected viral esophagitis.Strong recommendation, low quality of evidence. 3: ESGE recommends at least six biopsies are taken in cases of suspected advanced esophageal cancer and suspected advanced gastric cancer.Strong recommendation, moderate quality of evidence. 4: ESGE recommends taking only one to two targeted biopsies for lesions in the esophagus or stomach that are potentially amenable to endoscopic resection (Paris classification 0-I, 0-II) in order to confirm the diagnosis and not compromise subsequent endoscopic resection.Strong recommendation, low quality of evidence. 5: ESGE recommends obtaining two biopsies from the antrum and two from the corpus in patients with suspected Helicobacter pylori infection and for gastritis staging.Strong recommendation, low quality of evidence. 6: ESGE recommends biopsies from or, if endoscopically resectable, resection of gastric adenomas.Strong recommendation, moderate quality of evidence. 7: ESGE recommends fine-needle aspiration (FNA) and fine-needle biopsy (FNB) needles equally for sampling of solid pancreatic masses.Strong recommendation, high quality evidence. 8: ESGE suggests performing peroral cholangioscopy (POC) and/or endoscopic ultrasound (EUS)-guided tissue acquisition in indeterminate biliary strictures. For proximal and intrinsic strictures, POC is preferred. For distal and extrinsic strictures, EUS-guided sampling is preferred, with POC where this is not diagnostic.Weak recommendation, low quality evidence. 9: ESGE suggests obtaining possible non-neoplastic biopsies before sampling suspected malignant lesions to prevent intraluminal spread of malignant disease.Weak recommendation, low quality of evidence. 10: ESGE suggests dividing EUS-FNA material into smears (two per pass) and liquid-based cytology (LBC), or the whole of the EUS-FNA material can be processed as LBC, depending on local experience.Weak recommendation, low quality evidence.

Viral infections in inflammatory bowel disease: Tips and tricks for correct management

Over the past decades, the treatment of inflammatory bowel diseases (IBD) has become more targeted, anticipating the use of immune-modifying therapies at an earlier stage. This top-down approach has been correlated with favorable short and long-term outcomes, but it has also brought with it concerns regarding potential infectious complications. This large IBD population treated with immune-modifying therapies, especially if combined, has an increased risk of severe infections, including opportunistic infections that are sustained by viral, bacterial, parasitic, and fungal agents. Viral infections have emerged as a focal safety concern in patients with IBD, representing a challenge for the clinician: they are often difficult to diagnose and are associated with significant morbidity and mortality. The first step is to improve effective preventive strategies, such as applying vaccination protocols, adopt adequate prophylaxis and educate patients about potential risk factors. Since viral infections in immunosuppressed patients may present atypical signs and symptoms, the challenges for the gastroenterologist are to suspect, recognize and diagnose such complications. Appropriate treatment of common viral infections allows us to minimize their impact on disease outcomes and patients’ lives. This practical review supports this standard of care to improve knowledge in this subject area.

An Unusual Presentation of Herpes Esophagitis in an Immunocompromised Individual

Herpes simplex infection remains the third most common cause of esophagitis following gastric reflux disease and candida infection. This disease usually occurs in immunocompromised individuals; however, it has been frequently reported in healthy individuals. We present a case of a 39-year-old man who presented to the ER with symptoms unusual of herpes esophagitis. He was presumed to be immunocompromised due to uncontrolled diabetes mellitus and chronic alcohol use. Endoscopy revealed features in favor of candidiasis; however, histopathology displayed characteristic features of herpes infection. Herpes esophagitis should thus be suspected in immunocompromised patients with an independent underlying pathology and treated early with antiviral agents like acyclovir to prevent impending complications.

A Patient with Eosinophilic Esophagitis and Herpes Simplex Esophagitis: A Case Report and Literature Review

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.

Persistent Herpes Simplex Virus Type 1 Infection of Enteric Neurons Triggers CD8+ T Cell Response and Gastrointestinal Neuromuscular Dysfunction

Behind the central nervous system, neurotropic viruses can reach and persist even in the enteric nervous system (ENS), the neuronal network embedded in the gut wall. We recently reported that immediately following orogastric (OG) administration, Herpes simplex virus (HSV)-1 infects murine enteric neurons and recruits mononuclear cells in the myenteric plexus. In the current work, we took those findings a step forward by investigating the persistence of HSV-1 in the ENS and the local adaptive immune responses against HSV-1 that might contribute to neuronal damage in an animal model. Our study demonstrated specific viral RNA transcripts and proteins in the longitudinal muscle layer containing the myenteric plexus (LMMP) up to 10 weeks post HSV-1 infection. CD3⁺CD8⁺INFγ⁺ lymphocytes skewed towards HSV-1 antigens infiltrated the myenteric ganglia starting from the 6^th week of infection and persist up to 10 weeks post-OG HSV-1 inoculation. CD3⁺CD8⁺ cells isolated from the LMMP of the infected mice recognized HSV-1 antigens expressed by infected enteric neurons. In vivo, infiltrating activated lymphocytes were involved in controlling viral replication and intestinal neuromuscular dysfunction. Indeed, by depleting the CD8⁺ cells by administering specific monoclonal antibody we observed a partial amelioration of intestinal dysmotility in HSV-1 infected mice but increased expression of viral genes. Our findings demonstrate that HSV-1 persistently infects enteric neurons that in turn express viral antigens, leading them to recruit activated CD3⁺CD8⁺ lymphocytes. The T-cell responses toward HSV-1 antigens persistently expressed in enteric neurons can alter the integrity of the ENS predisposing to neuromuscular dysfunction.

Herpes simplex virus esophagitis-clinical challenges in the elderly

A 77-year-old woman presented with a 2-week history of malaise, prostration, anorexia, abdominal pain, vomiting and diarrhoea. She had been taking systemic corticosteroids for the past year. During hospitalisation, renal insufficiency, ionic changes and liver function abnormalities were detected and corrected. However, the patient developed total dysphagia. UGE revealed multiple shallow ulcers below the cricopharyngeal level and in the distal oesophagus, with normal-appearing intervening mucosa. Histological examination allowed the diagnosis of herpes simplex virus esophagitis. Treatment with intravenous acyclovir was instituted for 14 days. In the elderly, herpetic esophagitis may present with non-specific complains, such as prostration or anorexia. In the reported case, dysphagia was only detected as a late symptom, addressing the importance of maintaining a high degree of suspicion for the diagnosis of herpes simplex virus esophagitis.

Rare Etiology of Odynophagia in a Female Adolescent

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.

Infectious diseases of the upper gastrointestinal tract

A broad spectrum of pathogens produce gastrointestinal disease. The ongoing spread of human immunodeficiency virus/acquired immune deficiency syndrome, the increased use of immunosuppressive therapy and the persistence of overcrowding and suboptimal sanitation in underdeveloped areas facilitate both disease transmission from environmental and foodborne sources and person-to-person transmission. Clinicians increasingly rely on endoscopic biopsy sample interpretation to diagnose gastrointestinal infections. Thus, pathologists must be aware of diagnostic features of a variety of microbial pathogens. Detection with molecular techniques also allows for correlation between infectious agents and their histopathological features, which has expanded our knowledge of the inflammatory changes produced by infectious agents. This review covers infectious disorders of the upper gastrointestinal tract encountered in surgical pathology. Clinical, endoscopic and pathological features are presented. The review emphasises morphological features of viruses, bacteria, fungi and parasites that may be found in tissue samples, and the inflammatory patterns that they produce. Differential diagnoses and useful ancillary techniques are discussed.

Epigastric pain associated with herpes esophagitis: case report

Background

Herpes esophagitis is uncommon disease caused by Herpes simplex virus (HSV). While the disease most often occurs in immunocompromised patients, including post-chemotherapy, immunosuppression with organ transplants, and in AIDS, Herpes esophagitis can also occur in immunocompetent individuals.

Case presentation

We report a case of herpes esophagitis in a 72 year- old woman who was presumed to be immunocompromised following prolonged radiotherapy and chemotherapy for lymphoma. Her main symptom was epigastric pain.

Upper endoscopy showed multiple rounded ulcers in lower esophagus. The diagnosis was confirmed histologically by multiple biopsies. The patient received Valacyclovir for 2 weeks and started to get better within 3 days of treatment.

Conclusion

Although there are few published cases of Herpes esophagitis disease in the medical literature, we recommend that this disease should be considered as one of the differential diagnoses when assessing immuno-compromised patients presenting with non-specific abdominal symptoms.

[Evaluation and management of infectious esophagitis in immunocompromised patients and immunocompetent individuals]

Among the many causes of the inflammatory process in the esophagus, infectious diseases are becoming increasingly important due to their steady growth. Previously esophageal infections have traditionally been associated with immunodeficiency syndromes, but now in clinical practice, these disorders are becoming increasingly recognized in immunocompetent individuals. Early diagnosis of infectious esophagitis is necessary to develop effective treatment tactics, and, as a result, reduce the risk of complications and adverse outcomes of the disease. This study reviewed the most clinical relevant pathogens of infectious esophagitis, both among patients with immunodeficiency and among healthy individuals. Specific diagnostic, risk factors, clinical presentation and therapeutic features were considered depending on the immune status of patients.

Herpetic esophagitis in immunocompentent host: cases report

BACKGROUND

Herpetic esophagitis (EH) usually affects those who are immunocompromised and is uncommon in immunocompetent patients. In these cases, EH may occasionally present as an acute and self-limited illness. Such cases are rare and only a few have beenreported and limited published reviews exist making the benefits of antiviral therapy in immunocompetent patients unknown.

CASE PRESENTATION

We report four cases of young patients who presented dysphagia, odynophagia and epigastric pain. Endoscopic findings revealed lesions in the distal esophagus and histopathological changes compatible with herpes virus infection confirmed by viral DNA in every case. After treatment, every patient showed significant improvement and tolerated oral intake after discharge.

CONCLUSIONS

In this publication, we present four immunocompetent patients with EH, without relevant alterations in laboratory workup and with negative HIV status. This disease is infrequent in patients with such characteristics and there are few cases published. In order to better understand this pathology, we present the symptoms, the endoscopic alterations and the clinical evolution with treatment. In our series, 50% of patients had serology compatible with acute HVS type 1 infection, 25% had a subacute infection pattern (IgM and IgG positive antibodies) and in another 25% of patients, serology was not done. No patient presented leukocyte alterations, while all patients presented with anatomopathological findings compatible with acute herpetic esophagitis and responded to acyclovir therapy.

Esophageal Cytomegalovirus and Herpes Simplex virus co-infection in an immunocompromised patient: Case report and review of literature

Herpes simplex virus and Cytomegalovirus co-infection has been reported to occur in a variety of sites in immunocompromised patients. To our knowledge, few cases of such co-infection have been reported to occur in the esophagus. We report a case of a 60-year-old woman who was maintained on immunosuppressive therapy for a presumed diagnosis of pemphigus vulgaris, who presented with odynophagia. Investigations revealed ulcerative esophagitis caused by both HSV and CMV. The patient was treated with valganciclovir with full recovery. We also present the results of various studies on patients with similar presentation particularly those caused by HSV and CMV co-infection.

HSV-1 Ulcers as an Infrequent Cause of Hematochezia

We report a 62-year-old woman in the intensive care unit who developed hematochezia. Her endoscopic findings revealed diffusely bleeding esophageal ulcers related to herpes simplex virus. The bleeding was treated successfully with Hemospray.

The controversial natural history of oral herpes simplex virus type 1 infection

The natural history of oral herpes simplex virus type 1 (HSV-1) infection in the immunocompetent host is complex and rich in controversial phenomena, namely the role of unapparent transmission in primary infection acquisition, the high frequency of asymptomatic primary and recurrent infections, the lack of immunogenicity of HSV-1 internalized in the soma (cell body) of the sensory neurons of the trigeminal ganglion, the lytic activity of HSV-1 in the soma of neurons that is inhibited in the sensory neurons of the trigeminal ganglion and often uncontrolled in the other neurons, the role of keratin in promoting the development of recurrence episodes in immunocompetent hosts, the virus-host Nash equilibrium, the paradoxical HSV-1-seronegative individuals who shed HSV-1 through saliva, the limited efficacy of anti-HSV vaccines, and why the oral route of infection is the least likely to produce severe complications. The natural history of oral HSV-1 infection is also a history of symbiosis between humans and virus that may switch from mutualism to parasitism and vice versa. This balance is typical of microorganisms that are highly coevolved with humans, and its knowledge is essential to oral healthcare providers to perform adequate diagnosis and provide proper individual-based HSV-1 infection therapy.

Simultaneous candida albicans and herpes simplex virus type 2 esophagitis in a renal transplant recipient

Renal transplant recipients are prone to opportunistic infections due to iatrogenic immunosuppression. Infectious esophagitis can present as an opportunistic infection in the post-transplant period. Common pathogens are candida, herpes simplex virus (HSV) and cytomegalovirus (CMV). Having a dual infection is uncommon and the diagnoses can be missed at initial presentation. Our patient, a 29-year-old African-American woman, status post deceased-donor-kidney transplant presented with difficulty and pain in swallowing with clinical features suggestive of candida esophagitis, confirmed by fungal culture. She did not get better with antifungal treatment. On further testing, the patient was found to have HSV-2 infection of the oesophagus as well. She received both fluconazole as well as acyclovir that lead to complete resolution of her symptoms. In the right clinical setting, esophagitis can be caused by more than one organism present at the same time and a high level of suspicion is warranted.

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

BACKGROUND AND AIMS

Herpes simplex esophagitis (HSE) is the second most common cause of infectious esophagitis and occurs in both immunocompetent and immunocompromised patients. The aim of this study was to reappraise the clinical course of HSE in different patient populations based on degree of immunocompetence and the presence or absence of underlying esophageal disease.

METHODS

Patients with histopathologically confirmed HSE identified from the Mayo Clinic pathology database from 2006 to 2016 were included in this study. Relevant demographic, clinical, and endoscopic data were retrospectively reviewed and compared between two cohorts: (a) immunocompromised and immunocompetent patients and (b) patients with and without underlying esophageal disorders.

RESULTS

Forty-six patients were included in the study. The most common presenting symptoms were odynophagia (34.8%) and dysphagia (30.4%). Thirty-three (71.7%) patients were immunocompromised, and these patients who experienced longer duration of symptoms (25.5 ± 23.4 days vs. 7.0 ± 5.5 days, p = 0.04) were more likely to require an extension of treatment course (38.1% vs. 8.3%, p = 0.05) compared to their immunocompetent counterparts. Seventeen (37%) patients had underlying esophageal disease, and these patients were more likely to have concomitant esophageal candidiasis (41.2% vs. 10.3%, respectively; p = 0.01).

CONCLUSION

Herpes simplex virus causes esophagitis in both immunocompetent and immunocompromised patients. While the disease course appears to be self-limited for all patient populations, clinical and endoscopic differences in the disease presentation and clinical course based on immune status and the presence or absence of underlying esophageal disease exist.

An uncommon case of herpetic esophagitis in a small child with allergic rhinitis: A case report and literature review (CARE compliant)

RATIONALE

Herpetic esophagitis (HE) is a common condition in immunosuppressed patients, but a rare entity in immunocompetent patients affecting especially male teenagers and young adults.

PATIENT CONCERNS

We report the case of a 5-year-old male patient, with a history of allergic rhinitis admitted in our clinic for acute onset fever refractory to antipyretics, chest pain, anorexia, refusal of solid food, accepting only small amounts of fluids, odynophagia, and epigastric pain. The clinical exam revealed severe malaise, pallor, decreased skin turgor, abdominal epigastric tenderness, heartburn at palpation within the epigastric area. The laboratory tests showed leukocytosis, monocytosis, hypoglycaemia, and elevated inflammatory biomarkers.

DIAGNOSES

The serology tests for human immunodeficiency virus (HIV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), and herpes simplex virus (HSV) were negative, except for immunoglobulin G (IgG) anti-EBV which was positive. The chest radiography was normal, and the abdominal ultrasound showed abdominal bloating. The upper digestive endoscopy revealed friable esophageal mucosa, with multiple ulceration on the entire esophagus, and whitish exudates especially on the middle and lower part of the esophagus suggesting a possible eosinophilic esophagitis or caused by Candida. Despite the empirical initiated treatment, the patient's evolution was only slowly favorable. The histological exam established the diagnosis of HE.

INTERVENTIONS

We initiated acyclovir therapy with an outstandingly favorable evolution.

OUTCOMES

After 1 month, we detected the seroconversion of IgG anti-HSV. The patient's follow-up revealed no additional complaints.

LESSONS

Despite its rarity in immunocompetent individuals, HE must be taken into account even in otherwise healthy small children. Allergic conditions might represent a predisposing factor for HE.

[Rare inflammatory diseases of the esophagus]

Because of its high incidence gastroesophageal reflux disease (GERD) is at the forefront of medical attention. On the other hand, vigilance for rare inflammatory diseases of the esophagus, such as herpes esophagitis, radiation-induced esophagitis, eosinophilic esophagitis, pseudodiverticulosis and Crohn's disease is low. Moreover, these entities are rarely distinguishable from GERD by clinical features alone. For all atypical and treatment refractory supposedly reflux diseases, the diagnosis should therefore be questioned and re-evaluated by endoscopy. When the macroscopic findings of esophagoscopy are ambiguous biopsies can be performed and histological examination then often leads to a definitive diagnosis. This is particularly important because the required treatment of rare forms of esophagitis often significantly differs from that of GERD.

A case report: asymptomatic esophageal eosinophilia after herpes simplex esophagitis. Controversies in the therapeutic approach

The coexistence of eosinophilic esophagitis and herpes simplex virus in patients has been published in numerous case reports in the last few years. Both entities can be diagnosed simultaneously or one prior to the other, raising a possible causal relationship. Esophageal eosinophilia is a histological finding, and its underlying cause should be investigated. Eosinophilic esophagitis is one of the most common causes of esophageal eosinophilia. Eosinophilic esophagitis is a clinicopathologic disease, which is characterized by dysphagia and food impaction. We present a case of a patient with asymtomatic esophageal eosinophilia diagnosed after herpetic esophagitis. Other causes of esophageal eosinophilia were ruled out. Given the recent association between eosinophilic esophagitis and esophagitis due to herpes simplex virus, we find ourselves facing a dilemma about assessing the need or not to initiate early treatment.

Endoscopic Management of Nonvariceal, Nonulcer Upper Gastrointestinal Bleeding

Nonvariceal, nonulcer upper gastrointestinal hemorrhage (UGIH) is a less common cause for acute upper gastrointestinal bleeding. However, nonvariceal, nonulcer UGIH is an important entity to identify and treat appropriately to prevent bleeding-related morbidity and mortality. Over the past 40 years, there has been a revolution in gastrointestinal endoscopy and a similar revolution in the management of UGIH. The aim of this article is to focus on the endoscopic management of nonvariceal, nonulcer UGIH, with a focus on the newer diagnostic and treatment modalities currently available.

Herpes Simplex Virus Esophagitis in Immunocompetent Children: A Harbinger of Eosinophilic Esophagitis?

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.

Esophagitis and its causes: Who is “guilty” when acid is found “not guilty”?

Esophagitis is mainly a consequence of gastroesophageal reflux disease, one of the most common diseases affecting the upper digestive tract. However the esophageal mucosa can also be targeted by some infectious, systemic or chemical conditions. Eosinophilic esophagitis (EoE) is an immune-mediated inflammatory disease, characterized by eosinophilic infiltration in the mucosa. Esophageal localization of Crohn’s disease is not very common, but it should always be considered in patients with inflammatory bowel disease complaining of upper digestive tract symptoms. There are also forms of infectious esophagitis (e.g., Herpes simplex virus or Candida albicans) occurring in patients with a compromised immune system, either because of specific diseases or immunosuppressive therapies. Another kind of damage to esophageal mucosa is due to drug use (including oncologic chemotherapeutic regimens and radiotherapy) or caustic ingestion, usually of alkaline liquids, with colliquative necrosis and destruction of mucosa within a few seconds. Dysphagia is a predominant symptom in EoE, while infectious, drug-induced and caustic damages usually cause chest pain and odynophagia. Endoscopy can be useful for diagnosing esophagitis, although no specific pattern can be identified. In conclusion when a patient refers upper gastrointestinal tract symptoms and the diagnosis of gastro-esophageal reflux disease is not convincing we should always carefully investigate the patient’s clinical history to consider possibilities other than the gastric refluxate.

Adenovirus-mediated shRNA interference against HSV-1 replication in vitro

The UL29 and UL28 proteins encoded by herpes simplex virus type 1 (HSV-1) are critical for its replication and packaging, respectively. Research has demonstrated that synthesized siRNA molecules targeting the UL29 gene are able to suppress HSV-2 replication and the UL28-null HSV-1 gene cannot form infectious viruses in vitro. Silencing the UL28 and UL29 genes by RNAi might lead to the development of novel antiviral agents for the treatment of HSV-1 infections. Two kinds of short hairpin RNAs (shRNAs) targeting the UL29 and UL28 genes were chemically synthesized and then delivered into cells by a replication-defective human adenovirus type 5 (Adv5) vector. (-) shRNAs targeting none of the genome of HSV-1 were used as the control. Vero cells were inoculated with Ad-UL28shRNA or Ad-UL29shRNA at a multiplicity of infection (MOI) of 100 and challenged 24 h later with HSV-1 at an MOI of 0.01 to inhibit HSV-1 replication, as measured by the level of the corresponding RNA and proteins. In addition, the amount of progeny virus was assessed at daily intervals. The antiviral effects of Ad-shRNAs at ongoing HSV-1 infection were explored at 12 h after inoculation of the HSV-1. The results showed that the shRNAs delivered by Adv5 significantly suppressed HSV-1 replication in vitro, as determined by the levels of viral RNA transcription, viral protein synthesis, and viral production. The Ad-UL28shRNA and Ad-UL29shRNA suppressed the replication of HSV-1, respectively, compared with the control group (P < 0.001). When Ad-UL28shRNA and Ad-UL29shRNA were combined, a synergistic effect was observed. The antiviral effects could sustain for at least 4 days after the HSV-1 infection (P < 0.001). Furthermore, antiviral effects were achieved 12 h prior to inoculation of Adv5-shRNAs (P < 0.001). Our data demonstrated comparable antiviral activities against herpes simplex virus by shRNAs targeting either UL29 or UL28 sites in vitro and the effectiveness of using the Adv5 delivery of shRNAs. Therefore, the Adv5 delivery of shRNAs targeting the UL29 and UL28 sites probably may provide an alternative strategy for controlling HSV-1 infection.

Herpetic esophagitis following bendamustine-containing regimen

A 76-year-old Japanese woman presented to our hospital with anorexia. Two years before, she was diagnosed with non-Hodgkin's lymphoma and had received ten cycles of systemic chemotherapy. After salvage chemotherapy with bendamustine and rituximab (B-R), bone marrow suppression had lasted >3 months. Esophagogastroscopy revealed polynesic white protrusions in the mid-esophagus. These lesions were diagnosed as herpetic esophagitis. To the best of our knowledge, there is no other report in which herpetic esophagitis has been documented as an adverse event of B-R regimen. Because the complication could cause symptomatic gastrointestinal discomfort, physicians should be aware of this disease.

Viral Spread to Enteric Neurons Links Genital HSV-1 Infection to Toxic Megacolon and Lethality

Herpes simplex virus 1 (HSV-1), a leading cause of genital herpes, infects oral or genital mucosal epithelial cells before infecting the peripheral sensory nervous system. The spread of HSV-1 beyond the sensory nervous system and the resulting broader spectrum of disease are not well understood. Using a mouse model of genital herpes, we found that HSV-1-infection-associated lethality correlated with severe fecal and urinary retention. No inflammation or infection of the brain was evident. Instead, HSV-1 spread via the dorsal root ganglia to the autonomic ganglia of the enteric nervous system (ENS) in the colon. ENS infection led to robust viral gene transcription, pathological inflammatory responses, and neutrophil-mediated destruction of enteric neurons, ultimately resulting in permanent loss of peristalsis and the development of toxic megacolon. Laxative treatment rescued mice from lethality following genital HSV-1 infection. These results reveal an unexpected pathogenesis of HSV associated with ENS infection.

Herpes Simplex Virus-2 Esophagitis in a Young Immunocompetent Adult

Herpes simplex esophagitis (HSE) is commonly identified in immunosuppressed patients. It is rare among immunocompetent patients and almost all of the reported cases are due to HSV-1 infection. HSV-2 esophagitis is extremely rare. We report the case of a young immunocompetent male who presented with dysphagia, odynophagia, and epigastric pain. Endoscopy showed multitudes of white nummular lesions in the distal esophagus initially suspected to be candida esophagitis. However, classic histopathological findings of multinucleated giant cells with eosinophilic intranuclear inclusions and positive HSV-2 IgM confirmed the diagnosis of HSV-2 esophagitis. The patient rapidly responded to acyclovir treatment. Although HSV-2 is predominantly associated with genital herpes, it can cause infections in other parts of the body previously attributed to only HSV-1 infection.

Acute Herpes Simplex Viral Esophagitis Occurring in 5 Immunocompetent Individuals With Eosinophilic Esophagitis

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.

Clinical Characteristics and Manifestation of Herpes Esophagitis: One Single-center Experience in Taiwan

We aimed to investigate the clinical characteristics of patients with herpes esophagitis (HE) based on endoscopic typing.Herpes simplex virus infection in the gastrointestinal tract primarily affects the esophagus. However, little is known about the presentation, endoscopic findings, and outcomes of HE.From 2003 to 2013, 47 patients with HE were identified histologically from among 1843 patients with esophageal ulcers. Personal data, underlying disease, esophagogastroduodenoscopy indication, endoscopic characteristics, pathological findings, laboratory data, and outcomes were collected. Endoscopic findings were classified into 3 types based on gross appearance and were correlated with clinical presentation.The mean age of patients was 62.04 ± 14.76 years, and most patients were men (39/47, 83%). The most common symptoms were odynophagia/dysphagia (20/47, 42.6%). Whereas 25 patients (53.2%) were diagnosed with malignancy, it was related to human immunodeficiency virus in only 1 patient (2.1%). HE was classified into 3 types based on endoscopic images: type I (n = 19), type II (n = 10), and type III (n = 18). The majority of patients with HE type III had sepsis (72%) and obvious leukocytosis than the other 2 types (P = 0.03). The overall mortality rate was 6.4% (3/47), and most of the patients who died (66.7% [2/3]) belonged to the endoscopic classification type III group. Clinical parameters were analyzed for the risk of poor outcome. Postchemotherapy and/or radiotherapy were associated with 30-day mortality after appearance of HE (P < 0.05).Herpes esophagitis primarily affects men and patients with malignancy or sepsis. However, the disease is usually self-limiting, and HE-related mortality is low. Relationship between severity of endoscopic findings and patients' outcome remains questionable. Further prospective study is needed.

Evaluation and Management of Infectious Esophagitis in Immunocompromised and Immunocompetent Individuals

Among the many inflammatory processes that may account for esophageal symptoms, infection represents an important etiologic category with numerous clinically relevant subdivisions. While features of the history and physical exam are informative, diagnosis often hinges on endoscopic visualization and histopathologic analysis. This chapter will review in series the most clinically relevant causative agents for infectious esophagitis, with specific diagnostic and therapeutic features of note divided into one of two immune milieus. Our discussion focuses primarily on Candida species, herpes simplex virus, and cytomegalovirus as the most common causes of infectious esophagitis while also addressing a number of less common pathogens worth keeping in mind.