Herpes simplex esophagitis in immunocompetent patients: a rare entity to consider.

Introduction

Herpes simplex virus (HSV) esophagitis causes dysphagia and odynophagia, usually associated with immunosuppression. However, it can also occur in immunocompetent individuals, so it should be considered in the differential diagnosis when esophageal ulcerative lesions are found.

Clinical case

We present the case of a 42-year-old man with no relevant medical history who consulted for dysphagia, odynophagia, and fever lasting several weeks. A gastroscopy was performed, revealing multiple superficial fibrinous ulcers, mostly millimetric in size and rounded in shape, alternating with larger linear ulcers (up to about 20 mm) from the cervical esophagus to the esophagogastric junction. In the lower third, the ulcers were confluent and slightly more excavated, covering practically the entire circumference. Biopsies were taken for microbiological and pathological examination, which confirmed the diagnosis of herpes simplex infection.

Figure 1

Different stages of herpes simplex lesion in the esophageal mucosa A. Superficial longitudinal ulcers with normal surrounding mucosa, with a “volcano” appearance. B. Confluent, excavated ulcers covering practically the entire esophageal circumference. C Fibrinous ulcers, some rounded and others linear, well defined with normal surrounding mucosa.

Figure 2

Histological images of esophageal biopsies corresponding to the case of herpes simplex virus (HSV) esophagitis. A. H&E 40x: esophageal squamous epithelium with the presence of multinucleated cells with molded and frosted nuclei, consistent with herpes virus infection. B. H&E 20x: fibrinous-necrotic material with inflammatory cellularity and the presence of frosted nuclear inclusions, indicative of viral infection. C. IHC HSV: intense nuclear immunostaining with antibody for herpes virus, confirming the diagnosis of herpetic esophagitis.

Discussion

Herpes simplex esophagitis in immunocompetent individuals is a rare condition that should be considered in the differential diagnosis of dysphagia in young people[1]-[3]. Endoscopic findings may be suggestive, but the definitive diagnosis will be made by immunohistochemical analysis of biopsies from the edges of the ulcers[1],[2]. Although it usually resolves within several weeks, antivirals can accelerate the resolution of lesions and symptoms[1]-[3].

However, there is little evidence of the benefits of antiviral therapy in this patient profile[2]. Perforation and bleeding are complications, although rare[3]. Once the diagnosis is confirmed, immunosuppression should be ruled out in these patients (including HIV)[1]-[3].