Herpetiform esophagitis
| Herpetiform esophagitis |
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Herpetiform esophagitis is a viral infection of the esophagus caused byHerpes simplex virus. While the disease most often occurs in immunocompromised patients, including post-chemotherapy, immunosuppression with organ transplants[1] and in AIDS,[2] herpes esophagitis can also occur in immunocompetent individuals.[3] It is also known as herpes esophagitis or HSV esophagitis.
Clinical presentation
Patients with herpes esophagitis experience odynophagia, or painful swallowing and dysphagia. Other symptoms can include Esophageal food bolus obstruction[4]|food impaction, hiccups[5], weight loss, fever,[6] and on rare occasions upper gastrointestinal bleeding as noted in the image above[7] and tracheoesophageal fistula[8]. Frequently one can see herpetiform lesions in the mouth and lips.
Differential diagnosis
CMV, VZV as well as HIV infections of the esophagus can have a similar presentation. Tissue culture is the most accurate means of distinguishing between the different viral etiologies.[9] Caustic esophagitis, pill-induced esophagitis as well as yeast esophagitis can have a similar clinical presentation.
Diagnostic testing
Upper Endoscopy often reveals ulcers throughout the esophagus with intervening normal-appearing mucosa. In severe cases the ulcers can coalesce and on rare occasions have a black appearance known as black esophagus.[10] While the diagnosis of herpes esophagitis can be inferred clinically it can only be accurately diagnosed through endoscopically obtained biopsies with microscopic evaluation by a pathologist finding the appropriate inclusion bodies and diagnostic immunochemical staining.[11] False negative findings may occur if biopsies are taken from the ulcer rather than from the margin of the ulcer as the inclusion particles are to be found in viable epithelial cells. Viral tissue culture represents the most accurate means of diagnosing the precise etiology.
Therapy
Antivirals such as acyclovir 400 mg by mouth 5 times daily for 14 to 21 days, famciclovir 500 mg 3 times daily for 14 to 21 days and valacyclovir 1 gram 3 times daily for 14 to 21 days may be used. Intravenous acyclovir 5 mg/kg IV every eight hours for 7 to 14 days is reserved for individuals who cannot swallow due to the odynophagia, individuals with other systemic manifestations of herpes or severely immunocompromised individuals.
Prevention
Herpes simplex virus is commonly found in humans, yet uncommonly results in systemic manifestations. Suppression of HIV virus with antiretroviral medications, careful monitoring of immunosuppressive medications are important means of prevention. Antiviral prophylaxis such as daily acyclovir in immunocompromised individuals may be considered.
References
- ^ G. G. Miller; J. S. Dummer Herpes Simplex and Varicella Zoster Viruses: Forgotten but Not Gone. American Journal of Transplantation. 2007;7(4):741-747.
- ^ McBane RD; Gross, JB Jr. Herpes esophagitis: Clinical syndrome, endoscopic appearance, and diagnosis in 23 patients. Gastrointest Endosc 1991; 37:600.
- ^ Kato S; Yamamoto R; Yoshimitsu S; Shimazaki K; Ogawa S; Itoh K; Miura S Herpes simplex esophagitis in the immunocompetent host. Dis Esophagus. 2005; 18(5):340-4
- ^ Marshall, JB, Smart JR, 3d, Elmer, C, et al. Herpes esophagitis causing an unsuspected esophageal food bolus impaction in an institutionalized patient [letter]. J Clin Gastroenterol 1992; 15:179.
- ^ Mulhall, BP, Nelson, B, Rogers, L, Wong, RK. Herpetic esophagitis and intractable hiccups (singultus) in an immunocompetent patient. Gastrointest Endosc 2003; 57:796.
- ^ Kato S; Yamamoto R; Yoshimitsu S; Shimazaki K; Ogawa S; Itoh K; Miura S Herpes simplex esophagitis in the immunocompetent host. Dis Esophagus. 2005; 18(5):340-4
- ^ Takeno M; Adachi H; Nakahama T Herpes esophagitis presenting with upper gastrointestinal bleeding: report of a case Nippon Shokakibyo Gakkai Zasshi. 2002; 99(8):935-40
- ^ Obrecht, WF Jr, Richter, JE, Olympio, GA, Gelfand, DW. Tracheoesophageal fistula: A serious complication of infectious esophagitis. Gastroenterology 1984; 87:1174.
- ^ Meinhard Classen; Guido N. J. Tytgat; M.D. Ph.D. (2010). Gastroenterological Endoscopy. Thieme. pp. 490–. ISBN 9783131258526. Retrieved 26 June 2010.
{{cite book}}: Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Nagri S; Hwang R; Anand S; Kurz J Herpes simplex esophagitis presenting as acute necrotizing esophagitis ("black esophagus") in an immunocompetent patient. Endoscopy. 2007; 39 Suppl 1:E169
- ^ William E. Bennett, Jr; Phillip I. Tarr Enteric Infections and Diagnostic Testing. Curr Opin Gastroenterol. 2009;25(1):1-7.