Glossitis and esophagitis from herpes simplex virus type 1 infection

Abstract

An 81-year-old woman presented to the emergency department with a 2-week history of malaise, fever and anorexia, with oral pain and odynophagia. Her medical history was remarkable only for type 2 diabetes mellitus. She was not taking any immunosuppressive agents. Her body temperature was 37.7°C, and other vital signs were normal. Physical examination showed multiple yellowish-white, pseudomembranous lesions on the patient's tongue (Figure 1A). The rest of the physical examination was unremarkable. Esophagogastroduodenoscopy showed multiple shallow ulcers with a white coating (Figure 1B and Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/ cmaj .210352/tab-related-content). Glossal and esophageal biopsies showed multinucleated cells with moulded, groundglass nuclei (Appendix 2, available at www.cmaj.ca/lookup/ doi/10.1503/cmaj.210352/tab-related-content). Results from polymerase chain reaction and immunohistochemical staining of the specimens were positive for herpes simplex virus type 1 (HSV-1), and we diagnosed herpetic glossitis and esophagitis. We did not find any evidence of malignant disease on a whole body computed tomography scan and upper and lower endoscopy. The patient's HIV test result was negative and her hemoglobin A 1c was 7.2%. We treated her with a 7-day course of acyclovir, intravenously because of her odynophagia, and the oral and esophageal lesions completely resolved.Herpes labialis is the most common manifestation of HSV-1 infection, accounting for about 90% of reactivated infections. 1 In contrast, herpetic glossitis and esophagitis are uncommon manifestations of HSV-1 infection. The macroscopic findings of herpetic glossitis are diverse, including single or multiple vesicles, ulcers, linear or crosshatched fissures and pseudotumoral plaques, as with our patient. 2 The differential diagnosis includes oral candidiasis, syphilis, tuberculosis, pemphigus, lichen planus and hairy leukoplakia. 3 Herpetic glossitis can coexist with herpetic esophagitis, and esophagogastroscopy should be considered if the patient has odynophagia. Herpetic esophagitis characteristically manifests as well-circumscribed ulcers that are sometimes described as having a volcano-like appearance (Appendix 1). 4 Diagnosis of herpetic glossitis and esophagitis can be made clinically if the presentation is typical; otherwise, virological confirmation is necessary to differentiate the disease from other entities. 1 Treatment consists mainly of antiviral agents, including acyclovir, valacyclovir and famciclovir, after considering the patient's immune status and disease severity.

Herpetic Esophagitis: A Cause of Dysphagia in a Malnourished Patient

“…Some authors argue that treatment differs according to the immunological status of the patient and clinical severity [ 1 , 8 - 9 ]. Although spontaneous resolution usually occurs after one to two weeks, patients may improve more quickly if treated with a short course of acyclovir, which may be beneficial in accelerating the resolution of the symptoms, with minimal or no toxicity [ 1 , 6 , 10 ].…”