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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.110 no.7 Madrid jul. 2018

http://dx.doi.org/10.17235/reed.2018.5508/2018 

SCIENTIFIC LETTERS

A case report: asymptomatic esophageal eosinophilia after herpes simplex esophagitis. Controversies in the therapeutic approach

Ainara Iriarte-Rodríguez1  , Itziar Frago-Marquínez2  , Gina-Patricia de-Lima-Piña3 

1Servicios de Aparato Digestivo. OSI Goierri-Alto Urola, Zumárraga. Guipúzcoa, Spain

2Servicio de Hospitalización a Domicilio. Hospital Universitario Araba. Vitoria, Spain

3Servicios de Anatomía Patológica. OSI Goierri-Alto Urola, Zumárraga. Guipúzcoa, Spain

Key words: Esophagitis; Herpes simplex virus; Esophageal eosinophilia; Eosinophilic esophagitis

Dear Editor,

A previously healthy 21-year-old male was admitted to our hospital due to a 4-day history of fever, odynophagia and dysphagia with a feeding intolerance. Laboratory examination identified a herpes simplex virus (HSV-1) primo-infection, without eosinophilia. Gastroscopy revealed severe esophagitis and the biopsy and culture were compatible with HSV-1. He was treated with acyclovir, lidocaine and Ziverel(r) and the symptoms disappeared. Since then, the patient has remained asymptomatic. A follow-up gastroscopy four months later suggested esophageal eosinophilia (Fig. 1) and the biopsies identified > 300 eosinophils per high-power field with eosinophil micro-abscesses. After a trial of omeprazole, a subsequent gastroscopy revealed persistent esophageal eosinophilia.

Fig. 1 Esophageal eosinophilia. 

Discussion

Patients with HSV-1 esophagitis usually present with dysphagia, odynophagia and fever. The diagnosis is confirmed via a biopsy or culture 1. The indication of acyclovir in immunocompetent patients is not well-known nowadays. However, early treatment could be an adequate option in order to shorten recovery times and avoid complications. Esophageal eosinophilia is a histological finding with an underlying cause that should be investigated. It is unusual in viral esophagitis, thus they are considered as separate entities.

Eosinophilic esophagitis (EoE) is the term used when esophageal eosinophilia occurs with clinical symptoms related to esophageal dysfunction. It is important to rule out other pathologies, especially proton-pump-inhibitor responsive esophageal eosinophilia. Once EoE is confirmed, the treatment options include topical corticoids or diet therapy 2. Several case reports have described the co-occurrence of EoE and HSV. They may be diagnosed simultaneously or successively, raising a possible causal relationship. It is thought that the entity which appears first produces a mucosal injury that favors the subsequent appearance of the second entity 3,4,5. Our patient probably first presented with herpetic esophagitis, which was treated. Subsequently, he was asymptomatic and esophageal eosinophilia was identified, the treatment of which is controversial. Therefore, the following questions are proposed:

  • Given the recent association between EoE and HSV, could this patient subsequently develop EoE?

  • Esophageal eosinophilia: is it better to treat or to wait?

  • Should the treatment be corticosteroids or diet based?

Bibliografía

1. Canalejo Castrillero E, García Duran f, Cabello N, et al. Herpes esophagitis in healthy adults and adolescents: report of 3 cases and review of the literature. Medicine (Balt) 2010;89(4):204-10. DOI: 10.1097/MD.0b013e3181e949ed [ Links ]

2. Molina-Infante J, Ferrando-Lamana L, Fernández-Bermejo M, et al. Eosinophilic esophagitis in GERD patients: a clinicopathological diagnosis using protein pump inhibitors. Am J Gastroenterol 2009;104:2856-7. DOI: 10.1038/ajg.2009.468 [ Links ]

3. Bustamante Robles KY, Burgos García A, Suárez Ferrer C. Eosinophilic esophagitis and herpetic esophagitis: cause or consequence? Rev Esp Enferm Dig 2017;109(5):393-4. DOI: 10.17235/reed.2017.4616/2016 [ Links ]

4. Fritz J, Lerner D, Suchi M. Herpes simplex virus esophagitis in immunocompetent children: a harbinger of eosinophilic esophagitis? J Pediatr Gastroenterol Nutr 2018;66(4):609-13. DOI: 10.1097/MPG.0000000000001748 [ Links ]

5. Zimmerman D, Criblez DH, Dellow ES, et al. Acute herpes simplex viral esophagitis occurring in 5 immunocompetent individuals with eosinophilic esophagitis. ACG Case Rep J 2016;3:165-68. DOI: 10.14309/crj.2016.38 [ Links ]