Imaging in Internal Medicine
This is a 75-year-old Saudi female, presenting with a history of 2-month dysphagia and odynophagia to solid mainly and cough tinged with blood. No history of vomiting, fever, change of voice. No history of pneumonia, recurrent infections or bronchial asthma. Also, no history of neck masses, weight loss or night sweats. No ear pain or dental infection. There was no history of recent antibiotic or corticosteroid use. She is a known case of diabetes mellitus, hypertension and dyslipidemia on medications. Patient is married, unemployed and nonsmoker. No previous similar complaint or significant family history.
Normal general physical examination except for small white patches at right side of the oropharynx with no ulceration or bleeding. No lymphadenopathy.
Upper gastrointestinal series showed upper esophageal web and esophageal tertiary contractions (Figure 1).
Neck computed tomography was done and showed fullness of left pyriform sinus and esophageal diverticulum (Figure 2).
Histopathology from the esophageal biopsy specimens revealed histologic features consistent with a focal ulceration with herpes viral infection. The HSV2 immunostaining was positive for rare viral inclusions, consistent with herpes viral infection ulcerative process. After the diagnosis was made, the patient started treatment with prednisone 30 mg for 10 days and famciclovir 500 mg for 14 days. The patient has dramatically improved over a period of nearly 2 weeks.
Esophagitis is mostly caused by non-infectious causes. Infectious esophagitis is most commonly caused by candid, herpes simplex virus (HSV) and cytomegalovirus. 1,2 HSV type 1 is the most common type and male to female ratio is 3:1; however, we are reporting a female case with HSV2.2
One of the well-known complications of immunosuppression is herpes simplex esophagitis (HSE) and it is rarely found in immunocompetent patients; which is, in this case, considered a self-limiting disease and rarely necrotic and diffuse.3,4
For patients with typical symptoms of esophagitis with no clear cause, specially if the ulcers involve distal or mild esophagus, HSE should be suspected and investigated even in immunocompetent patients regardless of the age or gender. Antiviral treatment is established for immunosuppressed patients and need more evidence for immunocompetent patients. We recommend antiviral treatment even for immunocompetent patients for the clear acceleration of the recovery time and prevention of possible complications.