UCTN – Unusual cases and technical notes E213 An unusual presentation of herpes simplex esophagitis: a nonhealing “peptic” ulcer A 58-year-old man presented with pro- A. G. N. Robertson, L. J. Dunn, gressive dysphagia, odynophagia, and A. Immanuel, S. M. Griffin heartburn. Past history included diabetes Northern Oesophago-Gastric Cancer Unit, mellitus and asthma. Current medica- Royal Victoria Infirmary, Newcastle Upon tions included oral and inhaled corticos- Tyne, UK teroids. Examination was unremarkable. Blood investigations were normal. Bar- References ium swallow demonstrated reflux esoph- 1 Fass R. Symptom assessment tools for gas- agitis. Endoscopy revealed circumferen- troesophageal reflux disease (GERD) treat- ment. J Clin Gastroenterol 2007; 41: 437– tial ulceration and a hiatus hernia. Biopsy 444 demonstrated an esophageal ulcer and 2 Baehr PH, McDonald GB. Esophageal infec- esophagitis with no evidence of malig- tions: risk factors, presentation, diagnosis, nancy. Despite high-dose treatment with and treatment. Gastroenterology 1994; proton pump inhibitors (PPI), ulceration 106: 509 – 532 3 Ramanathan J, Rammouni M, Baran J Jr et al. persisted. CT scan and endoscopic ultra- Fig. 1 Herpes esophageal ulceration. Herpes simplex virus esophagitis in the im- sonography showed a diffuse thick-wal- munocompetent host: an overview. Am J led proximal esophagus but no typical Gastroenterol 2000; 95: 2171– 2176 appearances of carcinoma. Regular en- doscopies over 2 years consistently re- Bibliography vealed a suspicious circumferential ulcer DOI 10.1055/s-0029-1214687 from 22 to 25 cm (l" Fig. 1). Endoscopy 2009; 41: E213 Georg Thieme Verlag KG Stuttgart · New York · Repeated biopsies suggested esophagitis ISSN 0013-726X with no evidence of malignancy, infec- tion, or Crohn’s disease. After 2 years, Corresponding author biopsies indicated herpes simplex. This S. Michael Griffin, MD, FRCS was confirmed by viral immunoglobulin Professor of Gastrointestinal Surgery levels and treated with aciclovir. Immu- Northern Oesophago-Gastric Cancer Unit nodeficiency was excluded. Follow-up re- Royal Victoria Infirmary vealed the patient to be asymptomatic. Newcastle upon Tyne Endoscopy demonstrated a completely NE1 4LP UK healed mucosa (l" Fig. 2). Fax: +44-191-2820237 Nonhealing gastroesophageal ulcers are [email protected] usually malignant. Most benign ulcers Fig. 2 Completely healed esophageal ulcer are peptic [1] and 85%–96% respond to after aciclovir therapy. high-dose PPI within 8 weeks [1]. Crohn’s disease is a rarer cause. Herpes ulcers are rare but have been docu- from viral culture or immunostaining of a mented in immunocompromised and im- biopsy from the ulcer edge. Patients re- munocompetent patients [2,3]. Herpes quire antiviral therapy [2]. simplex esophagitis is normallyself-limit- This is an unusual presentation of a This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. ing and associated with orolabial lesions herpes simplex esophageal ulcer, which [2]. Typical findings include superficial highlights the importance of repeated en- stellate ulcers in the mid esophagus [3]. doscopies and biopsies as features are not Advanced herpes simplex esophagitis always identified initially. It is important leads to plaques, “cobblestones”, and an to remember herpes simplex as a cause ulcerative appearance. Earlier stages have of a nonhealing ulcer or the chance for rounded vesicles which slough into sharp curative therapy may be missed. demarcated ulcers which may coalesce [3]. Herpes esophagitis is best diagnosed Endoscopy_UCTN_Code_CCL_1AB_2AC_3AZ Robertson AGN et al. An unusual presentation of herpes simplex esophagitis: a nonhealing “peptic” ulcer… Endoscopy 2009; 41: E213.