Herpes Esophagitis in Healthy Adults and Adolescents Report of 3 Cases and Review of the Literature

Herpes esophagitis (HE) is common in immunosuppressed patients, but has rarely been reported in immunocompetent individuals, in whom it appears to be a self-limited illness. We describe 3 new cases of HE in otherwise healthy patients seen in our hospital within the last 5 years. We performed a comprehensive review of the previously reported cases of HE in immunocompetent adults and adolescents in the English and Spanish literature. We analyzed the clinical features, treatment, and outcome of this entity. A total of 56 patients were included (39 men and 17 women), with a mean age of 35 years. The most common clinical manifestations were odynophagia (60.7%), fever (51.8%), and retrosternal chest pain (46.4%). A prodrome of upper respiratory symptoms and concurrent orolabial herpetic lesions were present in 26.8% and 25% of cases, respectively. Gastrointestinal bleeding was a rare complication (5.3%). Endoscopy revealed multiple ulcers in most cases (58.9%), typically involving the distal or mid-esophagus (83%). The diagnosis was confirmed by histopathologic examination in 40 cases (71.4%), by tissue viral culture in 21 (37.5%), and by detection of viral genome in esophageal samples in 4 cases (7.1%). Herpes simplex virus type 1 (HSV-1) was identified in 27 cases and herpes simplex virus type 2 (HSV-2) only in 1 case. Serology was consistent with a primary infection in 11 of the 25 evaluable cases (44%). Acyclovir therapy was used in 45.4% of patients. The outcome was favorable in all cases, although an esophageal perforation occurred in 1 patient. HE is a rare but well-defined entity in healthy adults and adolescents, and is probably underdiagnosed. A high degree of suspicion and a prompt endoscopic examination are required for the diagnosis. It is usually a self-limited infection, but early treatment with acyclovir may hasten the resolution of symptoms. Nevertheless, the benefit of antiviral therapy remains unknown.