Herpes esophagitis is a viral infection of the esophagus

Esophagus

The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...

 caused by Herpes simplex virus

Herpes simplex virus

Herpes simplex virus 1 and 2 , also known as Human herpes virus 1 and 2 , are two members of the herpes virus family, Herpesviridae, that infect humans. Both HSV-1 and HSV-2 are ubiquitous and contagious...

(HSV).

While the disease most often occurs in immunocompromised patients, including post-chemotherapy

Chemotherapy

Chemotherapy is the treatment of cancer with an antineoplastic drug or with a combination of such drugs into a standardized treatment regimen....

, immunosuppression with organ transplants and in AIDS

AIDS

Acquired immune deficiency syndrome or acquired immunodeficiency syndrome is a disease of the human immune system caused by the human immunodeficiency virus...

, herpes esophagitis can also occur in immunocompetent individuals.

Clinical presentation

Patients with herpes esophagitis experience odynophagia

Odynophagia

Odynophagia is painful swallowing, in the mouth or esophagus. It can occur with or without dysphagia, or difficult swallowing....

, or painful swallowing and dysphagia

Dysphagia

Dysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their dysphagia....

. Other symptoms can include food impaction

Esophageal food bolus obstruction

An esophageal food bolus obstruction is a medical emergency caused by the obstruction of the esophagus by an ingested foreign body...

, hiccups, weight loss, fever, and on rare occasions upper gastrointestinal bleeding

Upper gastrointestinal bleeding

Upper gastrointestinal bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon.Upper GI bleeds are considered...

 as noted in the image above and tracheoesophageal fistula

Tracheoesophageal fistula

A tracheoesophageal fistula is an abnormal connection between the esophagus and the trachea...

. Frequently one can see herpetiform lesions in the mouth and lips.

Differential diagnosis

CMV, VZV as well as HIV infections of the esophagus can have a similar presentation. Tissue culture is the most accurate means of distinguishing between the different viral etiologies. Caustic esophagitis, pill-induced esophagitis as well as yeast esophagitis can have a similar clinical presentation.

Diagnostic testing

Upper Endoscopy often reveals ulcers throughout the esophagus with intervening normal-appearing mucosa. In severe cases the ulcers can coalesce and on rare occasions have a black appearance known as black esophagus. While the diagnosis of herpes esophagitis can be inferred clinically it can only be accurately diagnosed through endoscopically obtained biopsies with microscopic evaluation by a pathologist finding the appropriate inclusion bodies and diagnostic immunochemical staining. False negative findings may occur if biopsies are taken from the ulcer rather than from the margin of the ulcer as the inclusion particles are to be found in viable epithelial cells. Viral tissue culture represents the most accurate means of diagnosing the precise etiology.

Therapy

Antivirals such as acyclovir 400 mg by mouth 5 times daily for 14 to 21 days, famciclovir

Famciclovir

Famciclovir is a guanine analogue antiviral drug used for the treatment of various herpesvirus infections, most commonly for herpes zoster . It is a prodrug form of penciclovir with improved oral bioavailability...

 500 mg 3 times daily for 14 to 21 days and valacyclovir 1 gram 3 times daily for 14 to 21 days may be used. Intravenous acyclovir 5 mg/kg IV every eight hours for 7 to 14 days is reserved for individuals who cannot swallow due to the odynophagia, individuals with other systemic manifestations of herpes or severely immunocompromised individuals.

Prevention

Herpes simplex virus is commonly found in humans, yet uncommonly results in systemic manifestations. Suppression of HIV with antiretroviral medications, careful monitoring of immunosuppressive medications are important means of prevention. Antiviral prophylaxis such as daily acyclovir in immunocompromised individuals may be considered.