Wayne State University, Detroit Medical Center Detroit, MI
Hamid-Reza Moein, MD1, Cale Sebald, DO2, Krishna C. Meka, DO2, Dongping Shi, MD1, Ahmad Abu-Rashed, MD, FACG1; 1Wayne State University, Detroit Medical Center, Detroit, MI; 2St. John Macomb-Oakland Hospital, Warren, MI
Introduction: Herpes simplex virus (HSV) esophagitis is rarely seen in immunocompetent patients. Symptoms include odynophagia, dysphagia, fever, and/or extra-esophageal herpetic lesions. A male predominance is noted with individuals being inflicted with the illness in the third to fourth decade. Although HSV esophagitis has typical punch-out lesions on endoscopy, it is very similar in appearance to cytomegalovirus (CMV) and should be confirmed by tissue biopsy. Upper gastrointestinal bleeding is a rare complication of HSV esophagitis. Treatment of HSV esophagitis in immunocompetent patients is controversial.
Methods: A 63-year-old African American woman with past medical history of chronic obstructive pulmonary disease (COPD) presented with acute shortness of breath and productive cough despite adherence to home medications. She was admitted for the management of a COPD exacerbation and treated with intravenous methylprednisolone, inhaled steroid (budesonide), bronchodilators (albuterol-ipratropium), and doxycycline. Prompt respiratory demise required intubation and transfer to the intensive care unit. She subsequently developed coffee ground emesis with associated drop in hemoglobin. An esophagogastroduodenoscopy (EGD) was performed which revealed punched-out esophageal ulcers and a non-bleeding superficial antral ulcer. Cold-forceps biopsies were taken from esophageal ulcers, which showed typical HSV histologic changes (multinuclear cells with ground glass appearance nuclei). Diagnosis was confirmed by positive immunohistochemical staining for HSV and negative staining for CMV. She was then treated with oral valacyclovir for 10 days. Repeat EGD for percutaneous endoscopic gastrostomy placement (1 day after completion of valacyclovir therapy) demonstrated complete resolution of previously noted esophagitis. Patient did not have any more gastrointestinal bleeding during admission. Discussion: HSV esophagitis, although rare, can occur in immunocompetent patients. A high index of suspicion is required as patients may present with upper gastrointestinal bleeding but without any systemic symptoms as in our case. HSV esophagitis should be considered in immunocompetent patients with COPD or asthma exacerbation who are receiving systemic steroid therapy and develop upper gastrointestinal bleeding. Valacyclovir may be used successfully in treatment of HSV esophagitis in immunocompetent patients.
Disclosures: Hamid-Reza Moein indicated no relevant financial relationships. Cale Sebald indicated no relevant financial relationships. Krishna Meka indicated no relevant financial relationships. Dongping Shi indicated no relevant financial relationships. Ahmad Abu-Rashed indicated no relevant financial relationships.