Journal of Gastroenterology and Hepatology | 2019
Gastrointestinal: An uncommon case of severe esophagitis
Abstract
A 77-year-old woman was admitted for iron deficiency anemia (hemoglobin 6 g/L). She had herpes simplex virus (HSV) encephalitis 3 years earlier complicated with post-encephalitic syndrome. Upon presentation, she was afebrile. No oral ulcers, genital ulcers, or vesicles were seen. Gastroscopy revealed LA grade D reflux esophagitis and sliding hiatus hernia (Fig. 1). Colonoscopy was unremarkable. Hematoxylin and eosin stained photomicrograph of esophageal biopsies demonstrating cells with nuclear molding and margination of the chromatin giving the nucleus am appearance reminiscent of ground glass (Fig. 2a). Immunochemical staining showed positive nuclear and cytoplasmic staining for HSV (Fig. 2b). She received 10 days of PO acyclovir 400 mg TDS and 8 weeks of esomeprazole 40 mg BD. Repeat gastroscopy 10 weeks later showed complete resolution of esophagitis with Schatzki ring at distal esophagus (Fig. 3). She tolerated oral diet well and hemoglobin improved to 11 g/L. HIV and diabetic screen were negative. Majority of HSV esophagitis (HSVE) in immunocompetent host had reactivation from prior HSV exposure. Although HSVE is uncommon among the immunocompetent host, perforation and bleeding had been reported. Esophageal biopsy has an important diagnostic role in severe esophagitis. Severe esophagitis with prior HSV infection should prompt endoscopists on HSVE, even in absence of typical endoscopic findings. Antiviral treatment is effective and can potentially avoid unnecessarily prolonged treatment with proton pump inhibitor.