E242 UCTN – Unusual cases and technical notes Herpes and cytomegalovirus esophagitis 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-esophagus; b,c the upper esophagus. A 46-year-old man who underwent a liver Fig. 2 Histological transplant in 2001 for fulminant hepatitis appearance of the of unknown etiology was diagnosed with esophageal ulcers a liver non-Hodgkin lymphoma (post- revealing: a herpes transplant lymphoproliferative disease) simplex virus (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 odynophagia 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). Biopsies taken from the ulcer base and borders confirmed herpes simplex 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 Gastroenterology 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 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. condition rapidly deteriorated and he discrete ulcers, coalescent ulcers, and of Medicine of the University of Porto, died from sepsis and liver failure. 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 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Albuquerque A et al. Herpes and cytomegalovirus esophagitis… Endoscopy 2012; 44: E242–E243.