E242 UCTN – Unusual cases and technical notes

Herpes and

Fig. 1 Upper gastrointestinal endoscopy in a 46-year-old transplant recipient who had recently been treated with high doses of steroids showing ulcerated mucosa in: a the mid-; b,c the upper esophagus.

A 46-year-old man who underwent a liver Fig. 2 Histological transplant in 2001 for fulminant appearance of the of unknown etiology was diagnosed with esophageal ulcers a liver non-Hodgkin lymphoma (post- revealing: a herpes transplant lymphoproliferative disease) simplex (HSV) in 2011. Some months later, he developed inclusions within the esophageal squamous an acute hepatocellular rejection that was cells; b cytomegalovirus treated with high doses of steroids. (CMV)-infected cells by The patient was admitted because of fever immunohistochemical and severe that was hinder- staining; c HSV-infected ing oral intake. He had multiple painful cells by immunohisto- ulcers on his tongue, palate, and oral mu- chemical staining. cosa. Upper gastrointestinal endoscopy revealed large superficial, circumferential ulcers with well-defined margins and yel- low exudate in the mid and upper esoph- agus (●" Fig.1). taken from the ulcer base and borders confirmed virus (HSV) and cytomegalovirus Esophageal ulcers due to CMV are typical- A. Albuquerque1, H. Cardoso1,2, (CMV) co-infection (●" Fig. 2). Polymerase ly large, shallow, solitary or multiple, and A. Ribeiro1, E. Rios3, R. Silva3, chain reaction (PCR) of the esophageal located in the mid or distal esophagus [3]. J. Magalhães3, G. Macedo1,2 mucosa for HSV and CMV DNA was posi- In HSV esophagitis, the morphology de- 1 Department, Hospital tive. Human immunodeficiency virus pends on the duration of infection [2] de São João, Porto, Portugal ’ (HIV) serology was negative. The patient s and includes nonspecific inflammation, 2 Gastroenterology Department, Faculty condition rapidly deteriorated and he discrete ulcers, coalescent ulcers, and of Medicine of the University of Porto, died from sepsis and . pseudomembranous esophagitis in the Portugal Patients with HIV infection, those on che- mid or lower esophagus. Ulcers due to 3 Pathology Department, Hospital São motherapeutic agents or steroids, and HSV are typically associated with a João, Porto, Portugal transplant recipients have a high frequen- yellowish exudate [4]. Three or more cy of esophageal infections, although biopsies are generally required to rule cases of multiple viral infections are very out viral esophagitis [5]. Co-infection rare [1]. Long-term high-dose corticoster- with HSV and CMV has a higher incidence oids may predispose to HSV and CMV in- of complications, namely perforation and fection, although they are much less com- bleeding [1]. monly diagnosed than Candida infections [2]. Endoscopy_UCTN_Code_CCL_1AB_2AC_3AZ

Competing interests: None

Albuquerque A et al. Herpes and cytomegalovirus esophagitis… Endoscopy 2012; 44: E242–E243 UCTN – Unusual cases and technical notes E243

References Bibliography Corresponding author 1 Vodovnik A, Cerar A. Synchronous herpes DOI http://dx.doi.org/ A. Albuquerque, MD simplex virus and cytomegalovirus esopha- 10.1055/s-0032-1309385 Gastroenterology Department gitis. Z Gastroenterol 2000; 38: 491–494 Endoscopy 2012; 44: E242–E243 Hospital de São João 2 Baehr PH, McDonald GB. Esophageal infec- © Georg Thieme Verlag KG Alameda Professor Hernâni Monteiro tions: risk factors, presentation, diagnosis, Stuttgart · New York 4200-319 Porto and treatment. Gastroenterology 1994; ISSN 0013-726X Portugal – 106: 509 532 Fax: +351-225-025766 Weile J Streeck B Muck J 3 , , et al. Severe cyto- [email protected] megalovirus-associated esophagitis in an immunocompetent patient after short-term steroid therapy. J Clin Microbiol 2009: 3031–3033 4 McBane RD, Gross JB. Herpes esophagitis: Clinical syndrome, endoscopic appearance, and diagnosis in 23 patients. Gastrointest Endosc 1991; 37: 600 5 Srilatha PS, Suvarna N, Gupta A et al. Esoph- ageal ulcer in a HIV-seropositive patient co- infected by herpes simplex and cytomegalo- virus. Indian J Pathol Microbiol 2011; 54: 219–220

Albuquerque A et al. Herpes and cytomegalovirus esophagitis… Endoscopy 2012; 44: E242–E243