P2423 - A Hard Case to Swallow: Co-Infectious Viral Esophagitis as a Complication of Steroid Use for Alcoholic Hepatitis

Willie C. Gilbert, DO¹, Anand Shah, MD^2
1Northside Hospital Gwinnett, Lawrenceville, GA; ²Emory University School of Medicine, Decatur, GA

Introduction: Infectious esophagitis is rare and found primarily in immunosuppressed or immunocompromised patients. Candida, herpes simplex virus (HSV) and cytomegalovirus (CMV) are the three leading causes of infectious esophagitis with co-infections of candida and HSV or candida and CMV, rare, but more frequent. The literature for co-infection with CMV and HSV is infrequent and has been previously reported in patients with AIDS. Here, we present a case of CMV and HSV esophagitis as a result of steroid use for alcoholic hepatitis.

Case Description/Methods: Patient is a 49-year-old male veteran with a medical history of alcohol use disorder, GERD, genital HSV on daily suppressive acyclovir treatment who was admitted for alcoholic hepatitis with a Maddrey’s Discriminant Function score of 72. He was started on prednisone. Day-4 Lille Score was 0.27 and veteran was discharged home on a 28-day steroid course. Nine days after starting steroid therapy, the veteran presented with chest pain, dysphagia, and odynophagia. Upper endoscopy revealed two large ulcers. The first was between 25-30cm from the incisors and the second was between 32-35cm. Biopsies and brushings were taken from the ulcers edge and centrally. Immunohistochemistry was positive for HSV1 and CMV. Cytology revealed multinucleated cells suggestive of HSV. Periodic acid-Schiff was negative for fungal organisms. Serum CMV DNA, IgG, and IgM antibodies were positive. HIV antibodies were unreactive. He was treated with proton pump inhibitors twice daily for 8 weeks, carafate four times daily for 1 week, and valganciclovir for 3 weeks with symptom improvement after completing 1 week of treatment. He completed the 28 days of steroids with a rapid taper. Repeat upper endoscopy demonstrated healed esophageal mucosa and small esophageal varices.

Discussion: Viral infectious esophagitis in a patient on steroids with impaired immunity secondary to alcoholic liver disease should be at the top of the differential diagnosis. Multiple viral infectious esophagitis is exceedingly rare with few cases reported in patients with HIV, cancer, on chemotherapy and steroids, or organ transplantation and typically associated with high morbidity and mortality. In this case, the veteran developed Listeria meningitis, bacteremia, and peritonitis three days after completing steroid therapy, indicative of the impaired immunity in patients with alcoholic liver disease and increasing appreciation for cirrhosis-associated immune dysfunction.


Disclosures:
Willie Gilbert indicated no relevant financial relationships.
Anand Shah indicated no relevant financial relationships.


Willie C. Gilbert, DO¹, Anand Shah, MD². P2423 - A Hard Case to Swallow: Co-Infectious Viral Esophagitis as a Complication of Steroid Use for Alcoholic Hepatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.