1. Herpes Simplex Esophagitis

2. Introduction - Herpes Simplex Virus Double-stranded DNA virus. Epithelial cells are the initial targets. HSV type 1 and 2 - different affinities body sites. Genital and oral area. HSV G-I mucosal infection : oral to anorectal infection. HSV 1 infection of esophagus : immunocompromised patient and solid organ and BM transplantation patient (KTP – 5% incidence). : occasionally, in healthy patient. but, rare.

3. Clinical Manifestation Odynophagia, Dysphagia, Fever, Epigastric pain, Nausea, Vomiting, and Heartburn. May have coexistent herpes labialis or oropharyngeal ulcers – not a typical finding. Compications : bleeding, T-E fistula, food impaction, intractable hiccup.

4. Differential Diagnosis Other causes of infectious esophagitis, especially in immunocompromised host. : Candida sp. – nearly 40% of cases, frequently accompanied by other pathogens including viruses. : CMV – Twice as common as HSV in HIV patients. : Other causes – Cyptococcosis, Histoplasmosis, Blastomycosis and Aspergillosis. - Mycobacterium and Nocardia.

5. Diagnosis Endoscopic findings : vary with the duration of infection. : Small (1 to 3 mm), rounded vesicles that usually involve the middle to distal esophagus. → Small, sharply demarcated ulcers that have raised margins and a yellowish base. → Large ulcers that can be covered with dense exudates resembling candidal plaques.

8. Biopsy and brushing cytology : Edge of ulcer. Histologic findings : Multinucleated giant cells, with ground-glass nuclei and eosinophilic inclusions that occupy up to one-half of the nuclear volume. Immunohistochemical stains for HSV. Viral culture – acyclovir-resistant strain.

10. Treatment Immunocompetent host : Spontaneous resolution or short course of oral acyclovir(1~2 wks). Immunocompromised host : 1. Acyclovir 400 mg PO five times a day for 2~3 wks. 2. Acyclovir 5mg/kg IV q 8 hrs for 1~2 wks. Foscarnet : Acyclovir-resistant strain. Famciclovir or Valacyclovir for oral therapy.

11. 국내 증례보고 1.A case of herpes simplex virus esophagitis by primary infection in an immunocompetent patient. Korean J Med. 2006 Mar;70(3):330-336. Korean. - 72 year-old immunocompetent male. 2.A Case of Herpes Simplex Virus Esophagitis in a Renal Transplant Child. Korean J Gastrointest Endosc. 2002 Mar;24(3):143- 146. Korean. - 9 year-old male, renal transplantation. 3. Herpes Simplex Esophagitis Presenting as Melena: A case report. Korean J Gastrointest Endosc. 2001 Jan;22(1):32- 35. Korean. - 29-year-old man, BM transplantation for CML.

12. 4.Herpes Simplex Esophagitis Following Cadaveric Renal Transplantation. J Korean Soc Transplant. 1999 Jun;13(1):177-181. Korean. - 43-years-old female, cadaveric KTP, immunosuppressive therapy and MPD pulse therapy for acute rejection. 5. Herpes Simplex Esophagitis: A report of two cases. Korean J Pathol. 1999 Apr;33(4):288-291. Korean. - Patient having chemotherapy for gastric carcinoma. 6.A Case of Herpes Esophagitis Confirmed by Electron Microscopic Findings. Korean J Gastrointest Endosc. 1991 Jun;11(1):73- 76. Korean. - 30- year-old immunocompetent male.

13. Cases 82 yrs old man with intermittent dyspepsia of 3 months’ duration. Yone-Han Mah, MD et al, Gastrointestinal endoscopy 2005;61:291-2. Severe bleeding from herpes esophagitis. Rattner HM et al, AJG 1985;80:523-5. 26-yr-old man with Mallory–Weiss tear. S. Kato, MD et al, Diseases of the Esophagus 2005;18:340–4. 40-yr-old woman with APN sepsis. Omer Nuri Pamuk, MD et al, AJG 2001;96:7-8.

14. Herpes Simplex Virus Esophagitis in the Immunocompetent Host : An Overview Jambunathan Ramanathan, MD et al. AJG 2000;95:2172-2176. 1. Rare but distinct entity, more common in male subjects. 2. Acute onset, systemic manifestations, and extensive erosive-ulcerative involvement of the mid- distal esophagus. 3. Histopathological examination alone may miss the diagnosis; adding tissue-viral culture optimizes the diagnostic sensitivity. 4. Usually self-limiting; whether antiviral therapy is beneficial remains unknown.