Transcript Herpes Simplex Esophagitis Introduction

Herpes Simplex Esophagitis
Introduction - Herpes Simplex Virus
• Double-stranded DNA virus.
• Epithelial cells are the initial targets.
• HSV type 1 and 2 - different affinities body sites.
Genital and oral area.
• HSV G-I mucosal infection : oral to anorectal infection.
• HSV 1 infection of esophagus
: immunocompromised patient and solid organ and
BM transplantation patient (KTP – 5% incidence).
: occasionally, in healthy patient. but, rare.
Clinical Manifestation
• Odynophagia, Dysphagia, Fever, Epigastric pain,
Nausea, Vomiting, and Heartburn.
• May have coexistent herpes labialis or oropharyngeal
ulcers – not a typical finding.
• Compications : bleeding, T-E fistula, food impaction,
intractable hiccup.
Differential Diagnosis
• Other causes of infectious esophagitis, especially in
immunocompromised host.
: Candida sp. – nearly 40% of cases, frequently
accompanied by other pathogens including viruses.
: CMV – Twice as common as HSV in HIV patients.
: Other causes – Cyptococcosis, Histoplasmosis,
Blastomycosis and Aspergillosis.
- Mycobacterium and Nocardia.
Diagnosis
• Endoscopic findings : vary with the duration of
infection.
: Small (1 to 3 mm), rounded vesicles that usually
involve the middle to distal esophagus.
→ Small, sharply demarcated ulcers that have raised
margins and a yellowish base.
→ Large ulcers that can be covered with dense
exudates resembling candidal plaques.
• Biopsy and brushing cytology : Edge of ulcer.
• Histologic findings
: Multinucleated giant cells, with ground-glass nuclei
and eosinophilic inclusions that occupy up to one-half
of the nuclear volume.
• Immunohistochemical stains for HSV.
• Viral culture – acyclovir-resistant strain.
Treatment
• Immunocompetent host : Spontaneous resolution or
short course of oral acyclovir(1~2 wks).
• Immunocompromised host :
1. Acyclovir 400 mg PO five times a day for 2~3 wks.
2. Acyclovir 5mg/kg IV q 8 hrs for 1~2 wks.
• Foscarnet : Acyclovir-resistant strain.
• Famciclovir or Valacyclovir for oral therapy.
국내 증례보고
1. A case of herpes simplex virus esophagitis by
primary infection in an immunocompetent patient.
Korean J Med. 2006 Mar;70(3):330-336. Korean.
- 72 year-old immunocompetent male.
2. A Case of Herpes Simplex Virus Esophagitis in a
Renal Transplant Child.
Korean J Gastrointest Endosc. 2002 Mar;24(3):143146. Korean.
- 9 year-old male, renal transplantation.
3. Herpes Simplex Esophagitis Presenting as Melena:
A case report.
Korean J Gastrointest Endosc. 2001 Jan;22(1):3235. Korean.
- 29-year-old man, BM transplantation for CML.
4. Herpes Simplex Esophagitis Following Cadaveric
Renal Transplantation.
J Korean Soc Transplant. 1999 Jun;13(1):177-181.
Korean.
- 43-years-old female, cadaveric KTP,
immunosuppressive therapy and MPD pulse therapy
for acute rejection.
5. Herpes Simplex Esophagitis: A report of two cases.
Korean J Pathol. 1999 Apr;33(4):288-291. Korean.
- Patient having chemotherapy for gastric carcinoma.
6. A Case of Herpes Esophagitis Confirmed by
Electron Microscopic Findings.
Korean J Gastrointest Endosc. 1991 Jun;11(1):73-76.
Korean.
- 30- year-old immunocompetent male.
Cases
• 82 yrs old man with intermittent dyspepsia of 3
months’ duration. Yone-Han Mah, MD et al,
Gastrointestinal endoscopy 2005;61:291-2.
• Severe bleeding from herpes esophagitis. Rattner
HM et al, AJG 1985;80:523-5.
• 26-yr-old man with Mallory–Weiss tear. S. Kato, MD
et al, Diseases of the Esophagus 2005;18:340–4.
• 40-yr-old woman with APN sepsis. Omer Nuri Pamuk,
MD et al, AJG 2001;96:7-8.
Herpes Simplex Virus Esophagitis in the
Immunocompetent Host
• : An Overview
Jambunathan Ramanathan, MD et al. AJG
2000;95:2172-2176.
1. Rare but distinct entity, more common in male
subjects.
2. Acute onset, systemic manifestations, and
extensive erosive-ulcerative involvement of the middistal esophagus.
3. Histopathological examination alone may miss the
diagnosis; adding tissue-viral culture optimizes the
diagnostic sensitivity.
4. Usually self-limiting; whether antiviral therapy is
beneficial remains unknown.