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Top of pageAbstractA 35-yr-old, immunocompetent male was admitted complaining of severe odynophagia.
Top of pageIntroductionHerpes simplex esophagitis usually occurs in immunocompromised or severely debilitated patients.
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Herpes simplex virus (HSV) is a common cause of ulcerative esophagitis in the immunocompromised or debilitated host.
40 years in 78% of cases), healthy male who presents with acute odynophagia, dysphagia, or heartburn, with or without prodromal symptoms (fever, pharyngitis, respiratory symptoms) or oral lesions.
However, it has also been well documented that esophagitis may occasionally occur as an acute, self-limited illness in immunocompetent patients (1, 2, 3, 4, 5).
Gastric ulcers associated with herpes simplex esophagitis in a nonimmunocompromised patient. Herpes simplex esophagitis in the immunocompetent patient: Report of four cases and review. Treatment of herpes simplex esophagitis in an immunocompetent patient with intravenous acyclovir. Acyclovir (ACV) therapy is a well established treatment for immunocompromised or severely debilitated patients (6, 7). However, ACV therapy in immunocompetent adults with esophagitis has been reported in only a few patients (2, 3, 4, 8, 9, 10). We report three cases of endoscopically-diagnosed HSVE in apparently immunocompetent children; two of these children had no evidence of herpetic lesions on the lips or oropharynx but proceeded to endoscopic and histopathological diagnosis because the clinical characteristics suggested that HSVE was present. DiscussionAfter candidiasis, HSV type I is the second most common cause of infectious esophagitis. Acyclovir therapy in immunocompetent adults with esophagitis has been described in only a handful of cases in the literature, although the therapy is well established in immunocompromised patients. We herein present an immunocompetent patient with herpes simplex esophagitis whose symptoms were dramatically resolved after ACV therapy, and we discuss the value of the treatment.Top of pageCase reportA 35-yr-old male office worker was admitted to our hospital complaining of odynophagia of 5 days duration with progression to the stage at which even swallowing his own saliva produced severe retrosternal pain. The patient had had a low grade fever and malaise for 3 days before the development of odynophagia. Herpes simplex esophagitis in the immunocompetent patients: Report of four cases and review. There was no history of vomiting, recent weight loss, previous gastrointestinal complaints, medications or ingestion of corrosives. Acyclovir therapy may be beneficial in immunocompetent patients with particularly severe odynophagia. He had no risk factors for acquisition of human immunodeficiency virus (HIV) or history of contact with anyone with HSV infection. Asmar, “Herpes simplex virus type 1 esophagitis in an immunocompetent adolescent,” Digestive Diseases and Sciences, vol.
The past history was totally noncontributory, with the patient specifically denying heartburn, odynophagia, and mucosal or skin vesicles or ulcers.
Herpes esophagitis in immunocompetent adults: Report of two cases and review of the literature. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.AbstractIntroduction. The duration of illness ranges from 4 to 9 days in those receiving antiviral therapy compared with 10 to 17 days in those receiving symptomatic treatment alone.
Endoscopy revealed multiple discrete ulcers with erythema in the upper esophagus and extensive confluent ulceration with necrotic exudates in the lower half of the esophagus [Figure 1]. Herpes simplex esophagitis is well recognized in immunosuppressed subjects, but it is infrequent in immunocompetent patients.
Although HSE is noted to be a self-limited condition, cases of immunocompetent patients experiencing significant complications, including gastrointestinal bleeding and esophageal perforation, have been reported [10]. Histological examination of the esophageal mucosal biopsies showed acute inflammation and intranuclear inclusions consistent with viral infection [Figure 2].


ConclusionsHSE should be suspected in otherwise healthy subjects (irrespective of age) with symptoms (odynophagia, heartburn) suggestive of esophagitis without obvious cause, particularly in patients with ulcerations in distal or mid-distal esophagus at endoscopy.
Esophageal ulceration in human immunodeficiency virus infection: Causes, response to therapy, and long-term outcome. An esophagogastroduodenoscopy revealed minute erosive area in distal esophagus and biopsies confirmed esophagitis and findings characteristic of Herpes Simplex Virus infection.
Khatib, “Herpes simplex virus esophagitis in the immunocompetent host: an overview,” American Journal of Gastroenterology, vol.
Esophagoscopy on admission revealed multiple punched-out ulcers, which became partially confluent in appearance, like a map, in the distal third of the esophagus (Fig. Immunological workup, including total immunoglobulins, immunoglobulin-G subclasses and T-lymphocyte subsets, were normal.
The patients was treated with high dose of protonpump inhibitor, sucralfate, and acyclovir, orally, with rapid resolution of symptoms. She had been diagnosed with nutcracker esophagus at age 18 months when she presented with dysphagia, irritability, and characteristic high-amplitude peristaltic contractions on esophageal manometry study.
The majority of symptomatic immunocompetent patients with HSE will present with an acute onset of esophagitis.
There was no history suggestive of gastroesophageal reflux (GER), foreign body ingestion, medication or ingestion of a corrosive substance.
Endoscopic biopsies from the ulcer edges should be obtained for both histopathology and viral culture. He was able to eat solid food, including toast, on day 7, and he was discharged from the hospital on the day 10. The follow-up esophagoscopy 4 days after discharge showed no lesions except for ulcer scars in the middle and distal thirds. Physical examination revealed a well-nourished, ill-looking girl with a temperature of 38°C, and moderate dehydration. HSE should be suspected in case of esophagitis without evident cause, even if the patient is immunocompetent. Upper endoscopy revealed multiple, discrete, small-diameter and well-circumscribed ulcers from the mid to lower esophagus [Figure 4].
When the diagnosis of HSE is confirmed, careful history and assessment for an immune disorder such as HIV infection is crucial, to look for underlying immune deficiency.1. The ulcers become partially confluent in appearance, like a map.Full figure and legend (170K)The histology of the biopsy specimen on the day of admission obtained from the edge of the ulcers showed the squamous epithelium in acute and chronic inflammation without evidence of viral inclusions and pseudohyphae.
Biopsies showed intranuclear viral inclusions and immunoperoxidase staining and viral culture were positive for HSV Type 1. Immunohistochemically, the epithelial cells were partially positive with a monoclonal antibody to herpes simplex virus type 1 (HSV-1). Herpes esophagitis: A cause of upper gastrointestinal bleeding in an immunocompetent patient. Both antibodies (ELISA) to herpes simplex virus type 2 on admission and at 2 wk after admission were all negative.Top of pageDiscussionAcyclovir (ACV), a nucleoside analog, is most active against herpes simplex virus (HSV).
Based on controlled clinical studies, it is now recognized that ACV therapy for labial and genital HSV infections safely and effectively reduces the duration and severity in both immunocompetent and immunocompromised patients (11, 12). This was preceded by a prodromal illness of headache, sore throat, generalized malaise and painful lip ulcer of one-week duration. As a general rule, the earlier that treatment begins, the more likelihood there is of influencing the disease (13).As for treatment of herpes simplex esophagitis, ACV therapy is established in immunocompromised patients (6, 7). There was no history of previous gastrointestinal complaints, recent weight loss, trauma, surgical procedures or endoscopy.
In the immunocompetent patients, however, esophagitis commonly occurs as an acute and self-limited illness. Shafran, “Herpes simplex esophagitis in the immunocompetent patient: report of four cases and review,” Clinical Infectious Diseases, vol. Physical examination revealed a well-nourished boy, with a temperature of 39°C and a crusted, possibly herpetiform lesion on his lower lip.


Even in immunocompetent patients, however, severe complications, including bleeding and esophageal perforation, have recently been reported (14, 15). Therefore, ACV as well as symptomatic therapy should also be considered for immunocompetent patients.In the literature, ACV therapy in otherwise healthy and immunocompetent adults with the esophagitis has only been reported in eight patients (2, 3, 4, 5, 6, 7). Because of the severity of his symptoms, he was treated with intravenous morphine and intravenous acyclovir. These observations suggest that therapy in immunocompetent patients may hasten the time to the resolution of symptoms. He had inflamed friable, ulcerated mucosa in the mid to lower esophagus with multiple small ulcers arranged linearly. In addition, therapy may be a prophylaxis against complications.It has been speculated that herpes simplex esophagitis in immunocompetent adults may be part of a first HSV-1 infection (1). In the present case, the serological findings were consistent with a first HSV-1 infection, based on a 4-fold rise in IgG antibodies and positive finding for IgM antibodies.
Biopsies showed an acute inflammatory infiltrate with exudates of neutrophils consistent with an adjacent ulcer, but no evidence of intranuclear inclusion bodies. Recently, it has been pointed out that the incidence of the first infection of HSV in adults has been increasing in the field of dermatology as a result of a significant decline in the acquisition of HSV-1 infection in childhood (12). Therefore, it is likely that the incidence of herpes simplex esophagitis in immunocompetent adults will also increase. Such cases frequently result in severe odynophagia, and treatment, therefore, will likely become more important.We believe that the early initiation of ACV therapy for herpes simplex esophagitis is beneficial not only in immunocompromised patients, but also in immunocompetent patients with particularly severe odynophagia.
There is a need for a controlled study to determine the clinical effects of ACV on esophagitis in immunocompetent patients.
In the young child refusal of oral intake may be due to both odynophagia as well as oral discomfort.
Additionally, since HSVE is a self limiting condition in the immunocompetent host, some patients may be diagnosed with reflux-associated symptoms if their clinical improvement coincides with the institution of acid-suppression therapy.HSVE in immunocompetent children usually represents primary, isolated infection, but may follow reactivation [4] and has been associated with gastric involvement in a few cases. Thomas, “Esophageal infections in immunosuppressed patients after marrow transplantation,” Gastroenterology, vol. As reported previously it is more common not to have concurrent oral lesions, although in the presence of oral lesions the patients may not have had endoscopy to examine whether esophagitis was present. Such trauma may result from GER, esophageal instrumentation, nasogastric drainage, ingestion of caustics or retained foreign body. All our patients had characteristic endoscopic findings of friable mucosa, numerous, superficial ulcers, some discrete and others arranged in a linear pattern, typically involving mid to distal esophagus. Silverman, “Herpes virus esophagitis, consistent with herpes simplex, visualized endoscopically,” Gastrointestinal Endoscopy, vol. Patient 1 had more extensive involvement of the entire esophagus with confluent ulcers covered with necrotic exudates, which was difficult endoscopically to differentiate from a candida infection.
We have not been able to isolate HSV from the esophageal tissue in Patient 3, probably because of the preceding antiviral therapy, but the clinical history, presence of typical cold sore on his lip, typical endoscopic findings, acute inflammation in esophageal biopsies, and seropositivity of HSV IgM made a probable diagnosis of HSVE.HSVE is usually self-limited with a favorable outcome in the majority of immunocompetent patients. Careful history-taking is important to look for an underlying immunologic disease or risk factors for HIV infection.The mainstay of therapy is maintenance of hydration, nutrition and adequate analgesia including acid suppression therapy. In patients 2 and 3, symptomatic relief occurred within 48 h after instituting intravenous acyclovir.
Brown, “A comparison of PCR with virus isolation and direct antigen detection for diagnosis and typing of genital herpes,” Journal of Medical Virology, vol.
The duration of symptoms in patients receiving symptomatic treatment only, ranged between 2-20 days after presentation.
We feel that early initiation of acyclovir may shorten the clinical course of the disease, particularly in patients with severe odynophagia.HSVE remains an unusual infection in healthy children but probably occurs more often than is currently recognized, and should be considered in any child presenting with odynophagia even in the absence of skin or oropharyngeal lesions. Caddy, “A rare cause of dysphagia: herpes simplex esophagitis,” World Journal of Gastroenterology, vol.



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