S828 Adult Eosinophilic Esophagitis With Candida, HSV, and CMV Co Infections: A Systematic Review and Unique Dual HSV Case Report
Bibliographic record
Abstract
Introduction: Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease defined by ≥15 eosinophils per high-power field and driven by Th2 inflammation. While Candida, herpes simplex virus (HSV), and cytomegalovirus (CMV) esophagitis are typically seen in immunocompromised hosts, emerging evidence suggests these infections may also affect immunocompetent adults with EoE due to epithelial barrier dysfunction and localized immunosuppression from swallowed steroids. To better characterize this overlap, we performed a systematic review of adult EoE cases with confirmed Candida, HSV, or CMV co-infection and present a rare case of dual HSV/EoE in an immunocompetent patient. Methods: We searched PubMed, Embase, and Web of Science (January 2015-January 2025) following PRISMA guidelines. Inclusion criteria were adult patients with histologically confirmed EoE and concurrent esophageal infection. Two reviewers independently screened studies, assessed quality using Newcastle-Ottawa and Joanna Briggs Institute tools, and extracted data on demographics, infection type, histology, treatment, and outcomes. Pooled estimates and narrative synthesis were performed. Results: Of 312 records, 13 met inclusion (12 prior cases and 1 new). Candida was most common among patients on topical steroids (16%; 95% CI 11.6-21.7%). HSV esophagitis preceded EoE in 67% of cases (95% CI 43.7-83.7%), while CMV was rare, mainly in elderly patients on budesonide. Histology revealed eosinophilic inflammation alongside fungal hyphae or viral inclusions. Our case involved a 40-year-old immunocompetent men with potassium pill impaction. Endoscopy showed severe stricture, 37-55 eos/hpf, and acute ulcerative HSV esophagitis. He improved with high-dose proton pump inhibitor and valacyclovir. Conclusion: This review highlights that infectious esophagitis and EoE are not mutually exclusive, even in immunocompetent adults. Disruption of epithelial barriers by Th2 inflammation, downregulation of junctional proteins (e.g., desmoglein-1 via Interleukin-13), and local immunosuppression from topical steroids may predispose to Candida, HSV, or CMV superinfection. In our case, pill impaction revealed underlying dual pathology. Across cases, dual-site biopsies—sampling both ulcerated and intact mucosa—were critical for diagnosis. A coordinated strategy including antimicrobials, acid suppression, cautious dilation, and delayed steroid initiation is key to optimizing outcomes and avoiding complications in dual-pathology esophagitis.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.005 | 0.022 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.006 | 0.004 |
| Bibliometrics | 0.014 | 0.013 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.002 | 0.002 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.002 | 0.001 |
| Insufficient payload (model declined to judge) | 0.006 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".