P1424 - Acute Esophageal Necrosis Caused by HSV Infection

Akhila Madala, MD¹, Zoheb I. Sulaiman, DO², Joshuam Ruiz Vega, MD¹, Maureen Onweni, MD¹, Nathaniel Rodriguez, MD², Gregory Smith, MD^3
1AU/UGA Medical Partnership, Athens, GA; ²AU UGA Medical Partnership at St. Mary's Hospital, Athens, GA; ³Athens Gastroenterology Center and Athens Endoscopy, Athens, GA

Introduction: Herpes simplex esophagitis typically affects immunocompromised patients and is rarely seen in immunocompetent patients. Its presentation consists of acute odynophagia, fever, and retrosternal chest pain. If severe, it can present as acute esophageal necrosis (AEN). An early upper gastrointestinal endoscopy is required for diagnosis. The incidence of AEN is 0.1-0.28% and men are four times more commonly affected. The prognosis of patients with AEN is poor with a mortality rate of 32% associated with the severity of underlying illnesses. We present an unusual presentation of severe herpes esophagitis in an immunocompetent host after a prolonged hospitalization.

Case Description/Methods: A 51-year-old female with a history of learning disability and insulin-dependent diabetes mellitus presented for a right hip fracture requiring ORIF. On post op day 11, she developed acute respiratory failure requiring intubation. After intubation, large amounts of coffee ground emesis was suctioned via OG tube with an acute drop in hemoglobin from 10 to 7 mg/dL. Endoscopy revealed necrotic circumferential esophagitis with blood clots in the entire esophagus, cardia, and gastric fundus (Images A,B,C). Esophageal biopsy obtained through EGD showed herpes esophagitis with extensive ulceration and rare fungal yeasts consistent with Candida. Immunostaining also confirmed numerous positive cells for HSV. She was eventually extubated, but had recurrent dysphagia with her tube feeds requiring TPN. She completed a 14 day course of acyclovir and a 10 day course of fluconazole. Repeat EGD demonstrated the disappearance of the blood clots with underlying esophageal ulcers (Images D&E).

Discussion: HSV is a well known culprit in acute esophagitis and can occur in immunocompetent hosts with comorbidities (i.e. diabetes) and with physiologic stressors (i.e. surgery.). Immunohistochemistry is crucial in the diagnosis. Addition of viral cultures in suspected cases yields higher success in diagnosis. This case report highlights this association and allows the clinician to identify and manage this complication to reduce morbidity and mortality.


Figure: A, B & C are images from initial endoscopy.
A (Circumferential necrosis of the Mid Esophagus),
B (Necrosis, sloughing and bleeding of Lower Esophagus)
C (Bleeding accumulating in the Gastric Cardia)
D & E are images from repeat endoscopy 4 weeks later.
D (Healing ulcers in Mid Esophagus), E (Normal Gastric Cardia)


Disclosures:
Akhila Madala indicated no relevant financial relationships.
Zoheb Sulaiman indicated no relevant financial relationships.
Joshuam Ruiz Vega indicated no relevant financial relationships.
Maureen Onweni indicated no relevant financial relationships.
Nathaniel Rodriguez indicated no relevant financial relationships.
Gregory Smith indicated no relevant financial relationships.


Akhila Madala, MD¹, Zoheb I. Sulaiman, DO², Joshuam Ruiz Vega, MD¹, Maureen Onweni, MD¹, Nathaniel Rodriguez, MD², Gregory Smith, MD³. P1424 - Acute Esophageal Necrosis Caused by HSV Infection, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.