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Herpes Simplex Esophagitis

Herpes Esophagitis

Herpes esophagitis is an infectious inflammation of esophagus caused by two members of herpesvirus family, herpes simplex virus HSV-1 or HSV-2. It rarely affects immunocompetent hosts, thus it is an opportunistic infection for with the esophagus being the most frequent visceral target.


Initial presentation for herpes esophagitis (HE) is non-specific. The prodromal stage may mimic the common flu and includes a fever of about 39°C, malaise, reduction in weight, as well as pulmonary symptoms and sore throat. After flu-like symptoms, patients develop esophageal signs specifically, acute odynophagia, dysphagia for both fluids and solid foods, retrosternal pain, nausea and subsequent vomiting [1] [2]. Symptoms for immunocompetent subjects can be self-limiting thus hindering the process of diagnosis. Furthermore, prodromal symptoms of herpes esophagitis in immunocompetent patients may be absent and manifest as acute odynophagia and dysphagia. In some cases, the infection is mild in character or even asymptomatic [3].

HSV-specific signs such as oropharyngeal (herpes labialis) and genital lesions are not commonly concurrent with esophagitis but are described in about 20% of cases [4]. Herpes lesions may herald esophagitis, or may arise after esophagitis or may be absent [3] [4] [5].

Specifics of history data are important to exclude collateral immunological conditions and possible HIV infection. On the grounds that herpes esophagitis is an opportunistic infection, subjects prone to developing it are either immunocompromised or are taking immunosuppressive medications. For example, a patient with a chronic autoimmune disease takes systemic corticosteroids that act on suppressing the immune system [2] [4] [5]. Gastro-esophageal reflux disease (GERD) patients and radiation therapy participants should be considered at risk of developing HE. Those receiving chemotherapy and transplant recipients are also at high risk. Cases of patients with HE and prior nasogastric intubation are reported, So, history of surgical procedures and previous inpatient care should be obtained [3].

  • Outbreaks can be triggered by stress, acute illness, certain medications, fever, excess sunlight and the onset of menstruation in women. Related wiseGEEK Articles[wisegeekhealth.com]
  • A review of the literature revealed 21 other cases in immunocompetent adults; and, of these 21 patients, odynophagia was noted in 19, nine experienced fever, and oral lesions were found in five of these individuals.[ncbi.nlm.nih.gov]
  • The prodromal stage may mimic the common flu and includes a fever of about 39 C, malaise, reduction in weight, as well as pulmonary symptoms and sore throat.[symptoma.com]
  • Other signs of infection may include: joint pain chills fever general malaise (not feeling well) Your doctor will ask you about your medical history. They may also look into your esophagus with a small, lighted camera, called an endoscope.[healthline.com]
  • Primary infection may also be associated with systemic symptoms, such as fever and malaise. In general, the severity of symptoms and the number of lesions is considerably less with reactivation. (See 'Recurrent infection' below.)[uptodate.com]
  • This was preceded by a prodromal illness of headache, sore throat, generalized malaise and painful lip ulcer of one-week duration.[saudijgastro.com]
  • Fever with chills Pain in the joints Weakness and malaise How Do You Get Herpes In Esophagus? Herpes of the esophagus is caused by the HSV 1 and is the same virus which causes cold sores. It is communicated via mouth to mouth contact.[simple-remedies.com]
Intravenous Administration
  • Patients suffering from AIDS and serious illness may need intravenous administration of the anti viral medicines.[tandurust.com]
  • It is important to remind herpes esophagitis in cases of severe odynophagia even in immunocompetent hosts.[ncbi.nlm.nih.gov]
  • After flu-like symptoms, patients develop esophageal signs specifically, acute odynophagia, dysphagia for both fluids and solid foods, retrosternal pain, nausea and subsequent vomiting.[symptoma.com]
  • She also reported odynophagia, nausea immediately after eating, and reports that she has lost ten pounds.[shmabstracts.com]
Coffee Ground Emesis
  • A 54-year-old man with a history of well-controlled schizophrenia and living in an assisted-living facility for the mentally ill was admitted to the hospital because of coffee-ground emesis and melena.[doi.org]
  • Case 68 year-old male with end-stage renal disease and multiple myeloma presented with coffee ground emesis and hiccups of ten months duration. A year earlier, he received cycles of bortezomib and dexamethasone, remaining on lenalidomide.[ncbi.nlm.nih.gov]
Intermittent Dysphagia
  • Case 3: A 29-year-old man with a history of intolerance to certain fruits, intermittent dysphagia, and epigastric pain presented for suspected esophageal fish bone impaction.[acgcasereports.gi.org]
Epigastric Tenderness
  • The patient had epigastric tenderness, but the bowel sounds were normal and there was no rebound tenderness.[nejm.org]
Aphthous Stomatitis
  • Physical exam was significant for cachexia, temporal wasting, aphthous stomatitis involving the tongue and diffuse abdominal tenderness.[ncbi.nlm.nih.gov]
Chest Pain
  • Odynophagia and chest pain were each present in half of the cases, but 26% of patients had neither. Gastrointestinal bleeding was attributable to herpetic esophagitis in 30%.[mayoclinic.pure.elsevier.com]
  • Two days later, she complained of pleuritic chest pain and severe odynophagia.[aafp.org]
Retrosternal Chest Pain
  • The most common clinical manifestations were odynophagia (60.7%), fever (51.8%), and retrosternal chest pain (46.4%).[ncbi.nlm.nih.gov]
  • Esophageal involvement occurs by contact of HSV in saliva. [2] Common clinical manifestations of HSV esophagitis are odynophagia (60.7%), fever (51.8%), and retrosternal chest pain (46.4%). [1] The duration of symptoms is usually Characteristic endoscopic[jdeonline.in]
  • Usually, the main complaints of HE are reported as fever and appetite loss, with retrosternal chest pain due to esophageal stenosis secondary to mucosal edema, especially in cases of immunodeficiency. 3, 9, 10 Although there were no stenotic lesions or[dovepress.com]
Nikolsky's Sign
  • Autoantibody binding to these molecules leads to the loss of cell-cell adhesion in the epithelial suprabasilar layer, producing flaccid blisters on an erythematous base with a positive Nikolsky sign. 1 The blisters frequently rupture, leaving painful[mdedge.com]


When evaluating herpes esophagitis, radiological examination is inferior to endoscopy as HE findings are not specific for this type of disorder. Misdiagnosis as fungal esophagitis is a common error because this condition also presents with large lesions.

Endoscopy is necessary for both the examination of the esophagus and obtaining a biopsy specimen to confirm the diagnosis. In the early stage of HE, the macroscopic examination may reveal diffuse ulcerations with central depressions (volcano-like) that are yellow-white in color and variable in size. Edematous halo and white exudate can also be present. Subsequently, lesions may consolidate [6]. Most common site of ulcerations in infectious esophagitis is the lower third of the esophagus, although cases of the middle third and ulcerations throughout the esophagus are also present. Occurrence in upper third is less likely [3] [5]. The tendency to form superficial ulcers may be the characteristic feature distinguishing HE from esophagitis caused by cytomegalovirus (CMV), which in contrast is associated with deep ulcerations.

Biopsy analysis is imperative for correct diagnosis. The histological specimen of mucosa must be collected from margins of the ulcer. Microscopy will reveal a unique picture of herpes infection like acute inflammation, multinucleated giant cells with ground glass nuclei, as well as eosinophilic inclusions in the nuclei [2] [7]. Immunohistochemistry is also necessary to confirm the presence of HSV antigens [8].

Virus isolation and cell culture along with polymerase chain reaction (PCR) are also beneficial in confirming the diagnosis [9].

  • Laboratory evaluation revealed prerenal azotemia, iron deficiency anemia, leukocytosis and thrombocytosis. An esophagram revealed esophageal dysmotility, but no evidence of stricture.[shmabstracts.com]
Multiple Ulcerations
  • Upper gastrointestinal endoscopic examination showed multiple ulcerations throughout the mid- and distal esophagus. Bleeding from a Mallory-Weiss tear was also seen. Follow-up endoscopic examinations showed whitish exudates on day 5.[ncbi.nlm.nih.gov]
  • EGD showed multiple ulcers in the distal esophagus (Figure 3). Biopsies taken from the ulcers were immunohistochemically positive for HSV. In biopsies taken from normal appearing mucosa, there were no signs of eosinophilic esophagitis.[acgcasereports.gi.org]
  • Endoscopy revealed multiple ulcers in most cases (58.9%), typically involving the distal or mid-esophagus (83%).[journals.lww.com]
Viral Inclusion Body
  • Diagnosis of herpes simplex esophagitis (HSE) was established through histological analysis showing squamous epithelial cells with viral-inclusion-bodies, immunohistochemically positive for HSV (Figure 2).[acgcasereports.gi.org]
  • In a small review of 38 cases of immunocompetent individuals with HSE, microscopic findings consistent with acute and chronic inflammation were present, along with cytopathologic changes and viral inclusion bodies consistent with herpetic infection were[ncbi.nlm.nih.gov]


  • We present a case of herpes esophagitis after corticosteroid treatment for back pain including epidural steroid injections. Corticosteroids, especially local injections, are a common treatment for chronic back pain, but they are not without risk.[ncbi.nlm.nih.gov]


  • Fluoroscopy On double contrast studies, it manifests as multiple small ( Treatment and prognosis It is considered a self-limited condition and expected to resolve within two weeks, only managed with symptomatic treatment 1.[radiopaedia.org]
  • Prognosis is fairly good; and most people with herpes of the esophagus don’t seem to have any serious long-term health issues.[simple-remedies.com]
  • The prognosis is good with rapid diagnosis and proper treatment. Ultimately, the prognosis depends on the underlying disease process. (See Prognosis .) The history findings vary based on the type of esophagitis (eg, reflux or infectious).[emedicine.medscape.com]
  • Prognosis for esophagitis is normally good. Esophagitis can be caused by certain allergies. Being overweight increases the risk of esophagitis. Depending on the cause of esophagitis, there are various possible treatments.[medicalnewstoday.com]
  • Oesophageal symptoms, their causes, treatment and prognosis in patients with the acquired immunodeficiency syndrome. Gut. 1989; 30 :1033–1039. [ PMC free article ] [ PubMed ] [ Google Scholar ] 7. Steiner I., Kennedy P.G., Pachner A.R.[ncbi.nlm.nih.gov]


  • Although herpes simplex virus is a recognized cause of esophagitis in immunocompromised patients, it may also be the etiologic agent in otherwise healthy individuals. Odynophagia and dysphagia are the major symptoms.[ncbi.nlm.nih.gov]
  • General Usually immunodeficient. [1] Etiology: Herpes simplex virus. Gross/endoscopic Features: Ulcers with a "punched-out" appearance with a brown/red edge. Images Herpes esophagitis - endoscopy. (WC) www: Herpes esophagitis - gross (utah.edu).[librepathology.org]
  • The etiological agent is the herpes simplex virus (HSV), which is a double-stranded DNA virus classified into two subtypes: HSV-1 and HSV-2.[radiopaedia.org]
  • Viral tissue culture represents the most accurate means of diagnosing the precise etiology.[ipfs.io]
  • […] counts less than 200 cells/mm 3 CMV and idiopathic HIV ulcers usually occur with CD4 counts less than 200 Acute onset of symptoms is most common Large, flat ulcers 1cm Imaging Findings Endoscopy with biopsy is the best method of establishing a specific etiology[learningradiology.com]


  • Surgical Pathology of the Gastrointestinal System: Bacterial, Fungal, Viral, and Parasitic Infections provides pertinent clinical, diagnostic, and epidemiologic information that will be valuable to the practicing surgical pathologist.[books.google.com]
  • Many such techniques remain limited to research or epidemiologic use and are not typically available in the clinical laboratory.[ncbi.nlm.nih.gov]
  • (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection" and "Treatment of genital herpes simplex virus infection" .)[uptodate.com]
  • Epidemiology and Natural History Systemic sclerosis affects every race in every country.[nature.com]
Sex distribution
Age distribution


  • Pathophysiology The major pathophysiologic disturbance in scleroderma is the overproduction and deposition of cellular matrix proteins such as collagen, fibronectin, tenascin, fibrillin-1, and glycosaminoglycans, into affected organs, predominantly the[nature.com]
  • Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 46. Updated by: Jatin M.[medlineplus.gov]
  • Pathophysiology The pathophysiology of esophagitis depends on its etiology (see Etiology ).[emedicine.medscape.com]


  • Suppression of HIV with antiretroviral medications, careful monitoring of immunosuppressive medications are important means of prevention. Antiviral prophylaxis such as daily acyclovir in immunocompromised individuals may be considered.[en.wikipedia.org]
  • A herpes esophagitis infection is particularly alarming because most healthy immune systems prevent the virus from showing symptoms in the throat.[stdaware.com]
  • Your doctor might also prescribe the antiviral medication on a long-term basis to prevent you from developing recurring infections. Recovery times vary depending on your health.[healthline.com]
  • Prevention Herpes simplex virus is commonly found in humans, yet uncommonly results in systemic manifestations.[ipfs.io]
  • Randomised trial of efficacy and safety of oral ganciclovir in the prevention of cytomegalovirus disease in liver-transplant recipients. The oral ganciclovir international transplantation study group. Lancet, 350 (9093), 1729-33.[cscanada.net]



  1. Canalejo Castrillero E, García Durán F, Cabello N, García Martínez J. Herpes esophagitis in healthy adults and adolescents: report of 3 cases and review of the literature.Medicine (Baltimore). 2010 Jul;89(4):204-10.
  2. Marinho AV, Bonfim VM, Rodrigues de Alencar L, Pinto SA, de Araújo Filho JA. Herpetic Esophagitis in Immunocompetent Medical Student. Case Reports in Infectious Diseases. 2014. Article ID 930459.
  3. Généreau T, Rozenberg F, Bouchaud O, Marche C, Lortholary O. Herpes esophagitis: a comprehensive review. Clin Microbiol Infect. 1997 Aug;3(4):397-407.
  4. Ramanathan J, Rammouni M, Baran J, Khatib R. Herpes simplex virus esophagitis in the immunocompetent host: an overview. Herpes Simplex Virus Esophagitis in Immunocompetent Host.Am J Gastroenterol. 2000 Sep;95(9):2171-6.
  5. Geraci G, Pisello F, Modica G, Li Volsi F, Cajozzo M, Sciumè C. Herpes Simplex Esophagitis in Immunocompetent Host: A Case Report. Diagnostic and Therapeutic Endoscopy 2009. Article ID 717183.
  6. Lee B, Caddy G. A rare cause of dysphagia: Herpes simplex esophagitis. World Journal of Gastroenterology : WJG. 2007;13(19):2756-2757.
  7. Eymard D, Martin L, Doummar G, Piché J. Herpes simplex esophagitis in immunocompetent hosts. The Canadian Journal of Infectious Diseases. 1997;8(6):351-353.
  8. Yousufa T, Khana A, Wanga S, Blumensteinb B. Herpes Esophagitis in an Immunocompetent Teenager. J Med Cases. April 2015;6(4):173-175.
  9. Bansal RK, Ranjan P. Herpetic esophagitis: An uncommon cause of dysphagia. J Dig Endosc 2014;5:119-20.

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Last updated: 2019-07-11 21:22