A 23-year-old, immunocompetent female presented to the hospital with a history of dysphagia and odynophagia for a few days, without fever or other systemic symptoms. She had no past medical history and was not receiving regular medications. The patient underwent endoscopic examination. Upper gastrointestinal endoscopy revealed the presence of linear and oval-shaped ulcerations located in the middle and lower third of the oesophagus, from which targeted biopsies were obtained (Figure 1). The remainder of the upper gastrointestinal tract appeared normal. The histopathological examination showed ulcerated oesophageal mucosa with a superficial necroinflammatory coating. On the surface of the mucosa, hyperchromatic nuclei were observed without the presence of clear nuclear inclusions. The immunohistochemical test for herpes simplex virus (HSV) was positive (Figure 2). Testing for HSV immunoglobulin type M (IgM) was positive, while HIV testing was negative. The patient received antiviral oral treatment with valacyclovir at a dosage of 1000 mg 3 times daily for 7 days and showed gradual improvement in symptoms. Three months after treatment, the patient remains asymptomatic.

Herpetic oesophagitis typically occurs in immunocompromised individuals, such as those with HIV infection, transplant recipients, malignancies, or undergoing immunosuppressive therapy [1, 2]. Clinically, it presents with odynophagia, dysphagia, retrosternal chest pain, fever, and nausea. The most commonly affected parts are the mid and distal oesophagus [3]. Diagnosis can be confirmed by endoscopic findings and evidence of herpetic infection (serology, PCR), in addition to histopathological examination. Endoscopy reveals ulcers usually less than 2 cm with normal appearing mucosa. They are multiple and well circumscribed, occasionally exhibiting raised margins and exudative discharge [4].

In the literature and to the best of our knowledge, cases of HSV oesophagitis in immunocompetent patients have been described. Sbeih et al. reported the case of a 77-year-old male patient, who presented to the emergency department with odynophagia, epigastric pain, nausea, and vomiting. Upper endoscopy showed ulcerations in the oesophagus and the second portion of the duodenum. Biopsies were taken separately from the oesophagus and duodenum and a diagnosis of HSV oesophagitis and duodenitis was made [5]. In a case report by Padwale et al. a 68-year-old healthy female presented with odynophagia and haematemesis, while endoscopy revealed oesophageal ulcers, and biopsies confirmed HSV oesophagitis [6]. Alicea et al. described a 30-year-old healthy male patient with odynophagia, malaise, and fever, who reported daily vaping for more than 1 year. Endoscopy revealed HSV along with candida oesophagitis. Lung injury is a well-known complication of vaping, while infectious oesophagitis may be another [7]. Patel et al. reported a case of a healthy young man with a diagnosis of HSV oesophagitis, who 8 months later developed eosinophilic oesophagitis (EoE) [8] and vice versa [9]. There are two mechanisms proposed that may explain the relationship between herpes simplex virus oesophagitis and eosinophilic oesophagitis. The inflammation in EoE can make the mucosa more susceptible to infections, while having an HSV infection can cause a breach in the mucosal barrier with increased allergen penetration, which leads to an overactive immune system and eventual disruption of immune tolerance, leading to hypersensitivity and eosinophil recruitment [10–12].

Antiviral therapy with acyclovir is the standard treatment for HSV oesophagitis. This case highlights the importance of considering herpes simplex virus infection in the differential diagnosis of odynophagia and oesophageal ulcerations, particularly when endoscopic findings show characteristic lesions, even in immunocompetent host.

Funding

No external funding.

Ethical approval

Not applicable.

Conflict of interest

The authors declare no conflict of interest.

References