Herpes Esophagitis in an Immunocompetent Teenager

Herpes simplex virus (HSV) esophagitis is a rare infection in the immunocompromised host making it an even more rare condition in the immunocompetent population. Herpes esophagitis usually presents with the constellation of symptoms of odynophagia, dysphagia, fever and retrosternal chest pain. When immunocompetent patients present with odynophagia, the most common etiologies include pill induced esophagitis, toxic ingestion or severe reflux esophagitis. Rarely is infectious esophagitis from HSV, cytomegalovirus or candida considered. HSV is the most common cause of esophagitis typically from a reactivation of prior infection. In very rare cases does it present as a primary infection in the esophagus. We describe a case of HSV esophagitis in an 18-year-old immunocompetent host with no significant past medical history. He presented to his primary care physician with complaints of odynophagia and was prescribed a course of amoxicillin and prednisone syrup. He presented 4 days later to the emergency room with worsening odynophagia, retrosternal chest pain and anorexia. He was evaluated by the gastroenterology team and was taken for esophagogastroduodenoscopy (EGD), which revealed diffuse, bleeding, superficial ulcerations along the entirety of his esophagus. Biopsies were taken and subsequently found to be HSV positive. The patient was treated with intravenous acyclovir, a proton pump inhibitor and sucralfate suspension. HIV was tested and was found to be negative. No other causes of immunosuppression were found. We believe the patients’ initial presentation was in fact a primary infection of HSV esophagitis, which was exacerbated by his oral prednisone use. The purpose of this report was to highlight the rare occurrence of infectious esophagitis with HSV possibly worsened by oral prednisone use in an otherwise healthy, young individual. Also, this report should raise awareness of clinicians to diagnose HSV esophagitis and begin prompt treatment on such patients. EGD with biopsy is the gold standard diagnostic modality for HSV esophagitis and should always be considered in young patients who present with odynophagia even in the absence of other alarm features. There is often a typical mucosal appearance with superficial, well-demarcated, small ulcerations along the mid to distal esophagus. The treatment of choice for HSV esophagitis is acyclovir 5 mg/kg every 8 hours for 7 - 14 days. Symptoms for most immunocompetent patients resolve spontaneously in about 1 - 2 weeks. In confirmed cases of HSV esophagitis, it is important to reassess the patient for any underlying immunodeficiencies. Although rare, HSV esophagitis should be entertained especially given the correct constellation of history and symptoms. J Med Cases. 2015;6(4):173-175 doi: https://doi.org/10.14740/jmc2100w

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