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Herpes Simplex Esophagitis

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Some of the common causes of infectious esophagitis are candida, herpes simplex virus, and cytomegalovirus. The patients are usually immunocompromised due to chemotherapy or human immunodeficiency virus or following organ transplantation. The case shown here is from a renal transplant recipient. Some cases occur in immunocompetent individuals.

Herpes esophagitis is caused by HSV type 1. The patients usually present with odynophagia, chest pain, and fever. Other symptoms can include hiccups, food impaction, and weight loss. Rare cases develop upper gastrointestinal bleeding. Herpetiform lesions may be present in the mouth and lips.

Upper endoscopy shows shallow ulcers of variable sizes throughout the esophagus with intervening normal mucosa (see images 4 and 5). In severe cases, the ulcers coalesce and present as acute necrotizing esophagitis (aka "black esophagus"). The diagnosis is made by histopathologic examination of endoscopic biopsies which show acute inflammation, ulceration, and multinucleated giant cells with characteristic nuclear changes (nuclear molding and margination of chromatin).

Large eosinophilic intranuclear inclusions surrounded by a halo (Cowdry type A inclusions) are present in viable squamous epithelial cells at the margins of the ulcers. They contain intact and fragmented virions. Biopsies taken from the center of the ulcer rather than the margins may be falsely negative.

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