Endoscopy Challenge #1 - May '09

14 year old boy with odynophagia, dysphagia and chest pain

History

A 14 year-old healthy male presented with 5 days of worsening odynophagia, dysphagia, and mid-sternal chest pain. He described poor appetite and feeling of "food getting stuck." On review of systems, 4 days prior he had fever, body aches and emesis. Pertinent physical findings included mild mid-epigastric tenderness and a small vesicular lesion on his right thumb. Contrast esophagram was normal.

Diagnosis

Upper endoscopy demonstrated severe inflammation of the mid-distal esophagus with linear tracks of vesicular ulcerations and increased friability

Histologic evaluation revealed acute esophagitis with negative immunohistochemistry stain for HSV. Viral culture from esophageal ulcer was positive for HSV type I. In addition, right thumb viral culture also positive for HSV type I. He was treated with IV acyclovir, with significant improvement in symptoms within 24 hours. Workup for HIV was negative

Discussion

HSV esophagitis is rare in the immunocompetent host but has been described in literature1-3. In pediatric patients (<18 years old), a retrospective study revealed male predominance2. This condition is either a result of primary infection with HSV or reactivation of a latent infection2. Endoscopy is important in establishing the diagnosis but histopathology may not reveal viral inclusions. For this reason, viral culture or PCR for herpes simplex virus plays a significant role in diagnosis 1,2. Although it is self-limited in immunocompetent hosts, intravenous acyclovir may hasten resolution of symptoms 3 as seen in this case report.

Authors:

  1. Charina Ramirez, MD, Childrens Medical Center Dallas, University of Texas Southwestern
  2. Bradley Barth, MD, Children's Medical Center Dallas, University of Texas Southwestern

References

  1. Lee B, Caddy G. A rare cause of dysphagia: herpes simplex esophagitis: World J Gastroenterol 2007 13(19): 2756-57.
  2. Ramanathan J et al. Herpes simplex virus esophagitis in the immunocompetent host: an overview. Am J Gastroenterol 2000. 95(9):2171-6
  3. Kurahara K et al. Treatment of herpes simplex esophagitis in an immunocompetent patient with intravenous acyclovir: a case report nad review of literature. Am J Gastroenterol. 1998 93(11):2239-40.