Herpetic esophagitis in human immunodeficiency virus non infected patients

We report five cases of herpetic esophagitis in human immunodeficiency virus non-infected patients. Herpetic esophagitis is a frequent infection in immunocompromised patients. However, sixty four cases of herpetic esophagitis have been reported in immunocompetent patients. The infection presents non-specific esophageal symptoms. Diagnosis relies on esophageal histology and viral cultures. Treatment by acyclovir is recommended to prevent severe complications. This infection is probably underestimated in immunocompetent hosts but seems to be more frequent in patients with severe illness that can be responsible for transitory immunodeficiency. Biopsies of esophageal lesions should be systematically performed in these patients.     

Herpes Simplex Ulcerative Esophagitis in a Healthy Subject

A 20-year old white male developed a self-limited ulcerative esophagitis followed by a transient vesicular skin eruption due to infection by herpes simplex virus Type I (HSV-I). While herpetic esophagitis has been described previously, this case appears to be unique in that there was no concomitant serious delibitating illness or pharmacological immunosuppression. Herpes simplex Type I should be included in the differential diagnosis of unusual esophageal ulceration in otherwise healthy patients.     

Clinical impact of upper endoscopy in the management of patients with gastroesophageal reflux disease

OBJECTIVE: Esophago-gastro-duodenoscopy (EGD) is frequently performed in patients with heartburn. However, the benefit of an EGD is unclear. The objective is to determine the clinical impact of performing an EGD in the management of GERD. METHODS: Patients with alarm symptoms or persistent heartburn from primary care and gastroenterology clinics were invited to participate. Patients with known reflux complications or an EGD procedure within 3 yr were excluded. Endpoints for EGD-improving management were prospectively defined: change in medical therapy, dilating esophageal stricture, identifying Barrett's esophagus (BE), finding severe esophagitis (Hetzel-Dent grade 3 or 4), or finding cancer. RESULTS: Two hundred and six patients (59 M/147 F; median age, 48 yr) were enrolled, in which, 124 had alarm symptoms and 82 had persistent heartburn. EGD improved the overall management in 40% of patients with alarm symptoms and 29% with persistent heartburn (p= NS). Medical therapy was altered in only 5% of patients, and no cancer was identified. EGD was more likely to improve management in males with alarm symptoms. CONCLUSIONS: It was uncommon for an EGD to alter antireflux therapy. The management was improved in approximately one-third of the patients by dilating esophageal stricture, finding BE to initiate surveillance, or finding severe esophagitis. EGD should be performed when alarm symptoms are present, especially in males.     

Clinical effects of eosinophilic esophagitis observed using endoscopic ultrasound

A 50-year-old woman was referred to our hospital for dysphagia and several episodes of esophageal food impaction during the prior three months. Complete blood count and basic biochemical tests were normal. No eosinophilia was found. Esophagogastroduodenoscopy (EGD) revealed the presence of concentric rings (esophageal “trachealization”) and stenosis along the middle and distal esophagus. Endoscopic ultrasound (EUS) showed circumferential thickening of all layers in the same part. Cytopathologic evaluation of a specimen obtained by endoscopic biopsy of the thickened area in the distal esophagus showed eosinophilic infiltration (20 eosinophils per high-powered field). She was diagnosed as having eosinophilic esophagitis (EoE). Topical steroid therapy was started. A tendency of dysphagia for relief and improvement of characteristic EGD findings began early, but wall thickening in EUS remained. Past reports of the related literature have described that thickness of submucosa and muscularis propria remained after therapy, although significant reduction in the mucosal thickness was provided by short-term steroid therapy. One explanation for early relapse is insufficient reduction in the submucosa and muscularis propria. Consequently, our patient was given steroids until thickness on EUS improved. EUS is regarded as useful for evaluating the curative effect in patients with EoE.     

Esophageal dysplasia. Assessment by light microscopy and scanning electron microscopy

This study was performed to determine the characteristics of esophageal dysplasia by scanning electron microscopy. A total of 82 esophageal biopsy specimens were taken from 30 patients who were divided into three groups. Group 1 patients had no known esophageal disease. Group 2 patients had squamous cell cancer. Group 3 patients had esophagitis. Mucosal biopsy specimens that had been diagnosed by light microscopy as normal, esophagitis, or dysplastic mucosa were examined by scanning electron microscopy. A characteristic appearance for each type of mucosa was recognized by scanning electron microscopy. A quantitative analysis of the scanning electron microscopy feature of microridge density showed a statistically significant difference not only between normal and dysplastic mucosa, but also between esophagitis and dysplastic mucosa. The addition of scanning electron microscopy to light microscopy may prove helpful in the diagnosis of dysplasia as well as in the understanding of the biologic behavior of dysplastic cells and possibly their relationship to esophageal carcinoma.     

Herpes Simplex Esophagitis in a Renal Transplant Patient Treated with Cyclosporine A: A Case Report

Herpes simplex esophagitis is a rare disease occurring mostly in immunocompromised and cancer patients. We report the first case of herpes esophagitis in a renal transplant patient treated with Cyclosporine A while on chronic steroid therapy. With the increasing use of Cyclosporine A in transplant patients, the incidence of herpes esophagitis may increase. The disease is suggested endoscopically by its typical appearance. The diagnosis is confirmed by cytology, tissue studies, and viral cultures. Based on the limited knowledge of the natural history of herpetic esophagitis and lack of prospective antiviral trials, symptomatic therapy with viscous Xylocaine appears reasonable. The definitive role of antiviral therapy is yet to be clarified.     

Steakhouse syndrome causing large esophageal ulcer and stenosis

A 66-year-old man developed dysphagia during dinner and was evaluated 2d later in our hospital because of persistent symptoms.Upper gastrointestinal endoscopy showed no impacted food,but advanced esophageal cancer was suspected based on the presence in the upper esophagus of a large irregular ulcerative lesion with a thick white coating and stenosis.Further imaging studies were performed to evaluate for metastases,revealing circumferential esophageal wall thickening and findings suggestive of lung and mediastinal lymph node metastases.However,dysphagia symptoms and the esophageal ulcer improved after hospital admission,and histopathological examination of the esophageal mucosa revealed only nonspecific inflammation.At the timeof symptom onset,the patient had been eating stewed beef tendon(Gyusuji nikomi in Japanese) without chewing well.Esophageal ulceration due to steakhouse syndrome was therefore diagnosed.The lung lesion was a primary lung cancer that was surgically resected.Although rare,steakhouse syndrome can cause large esophageal ulceration and stenosis,so care must be taken to distinguish this from esophageal cancer.     

A prospective study of the diagnostic accuracy of PillCam ESO esophageal capsule endoscopy versus conventional upper endoscopy in patients with chronic gastroesophageal reflux diseases

INTRODUCTION: Endoscopy is commonly performed to evaluate for suspected or established esophageal diseases including gastroesophageal reflux disease (GERD) and its complications. The newly developed PillCam ESO Esophageal Capsule offers an alternative approach to visualize the esophagus and to evaluate patients with suspected esophageal disease. AIM: Compare the accuracy (specificity, sensitivity, positive predictive value [PPV], and negative predictive value [NPV]) of esophageal capsule endoscopy (ECE) compared with esophagogastroduodenoscopy (EGD) in evaluating patients with GERD. METHODS: A multicenter pivotal trial was conducted at seven sites. The PillCam ESO esophageal capsule is similar to the standard capsule endoscope used for the small bowel but acquires video images from both ends of the device at 2 frames/second/end. A total of 106 patients (93 GERD; 13 Barrett) underwent ECE followed by EGD. ECE videos were evaluated by an investigator blinded to EGD findings. A blinded adjudication committee reviewed all discrepant findings between ECE and EGD. RESULTS: Sixty-six of 106 patients had positive esophageal findings, ECE identified esophageal abnormalities in 61 (sensitivity, 92%; specificity, 95%). The per-protocol sensitivity, specificity, PPV, and NPV of ECE for Barrett esophagus were 97%, 99%, 97%, and 99%, respectively, and for esophagitis 89%, 99%, 97%, and 94%, respectively. ECE was preferred over EGD by all patients. There were no adverse events related to ECE. CONCLUSIONS: ECE is a convenient and sensitive method for visualization of esophageal mucosal pathology and may provide an effective method to evaluate patients for esophageal disease.     

The Preoperative Evaluation of Patients Considered for Laparoscopic Antireflux Surgery

Few studies address the proper extent of the preoperative testing in patients referred fur consideration of antireflux surgery. Our aim was to perform a thorough gastroesophageal evaluation and determine it's influence on the therapeutic decisions of such patients. We evaluated 107 consecutive patients in a combined GI/Surgery clinic for severe or refractory gastroesophageal reflux. The patients had an EGD, esophageal manometry, and 24-h ambulatory esophageal pli monitoring. Only patients with gastric symptoms had gastric testing. Nineteen patients were excluded, 12 refused further evaluation and seven were felt to be unfit for antireflux surgery because of medical or psychological reasons. Eighty-eight patients completed the required studies. Fifty-four patients (61%) had typical reflux symptoms and erosive esophaghis on EGD. All these patients had an abnormal pH study. Five of the 34 patients without esophagitis had a normal pH study and did not have surgery. Ten patients had poor peristalsis by esophageal manometry prompting a subtotal fundoplication. One patient had severe delayed gastric emptying, requiring pyloroplasty in addition to the fundoplication. Eighty of 83 patients had good or excellent surgical results. EGD and esophageal manometry are indispensable in the preoperativc evaluation. Manometry may identify abnormalities altering surgical decisions in roughly 10% of patients. Routine ambulatory esophageal pH monitoring is of marginal benefit, except in patients without esophagitis or in those patients where the diagnosis is in doubt. Clinically significant gastric abnormalities are rare, and routine testing of gastric function is not indicated.     

The Los Angeles and Savary–Miller systems for grading esophagitis: utilization and correlation with histology

The aim of the study is to determine the proportion of patients who have esophageal biopsy specimens taken for an endoscopic diagnosis of reflux esophagitis in which an endoscopic grade of esophagitis (Los Angeles [LA] or Savary–Miller [SM]) is communicated to the pathologist, and to evaluate the correlation between those endoscopic grades and histopathologic findings. We searched the database of Caris Diagnostics (a large, gastrointestinal pathology practice that receives specimens from community‐based endoscopy centers), and extracted data from all patients who had an endoscopy with esophageal biopsies submitted in a 12‐month period. There were esophageal biopsy specimens from 49 480 patients obtained during 58 986 endoscopies. The LA grade was provided in 5513 cases (27.9% of 19 778 with endoscopic esophagitis); the SM grade was stated in only 2416 cases (12.2%). A histopathologic diagnosis of erosive or ulcerative esophagitis was made significantly less often in LA grade A patients (3.2%) than in those with LA grades C (20.0%) and D (23.3%); erosive or ulcerative esophagitis was found in only 1.4% of patients with SM grade I and in 35.5% of cases with grade IV. Endoscopists who biopsy the esophagus of patients with reflux esophagitis usually do not communicate the grade of esophagitis to the pathologist. Although both the LA and SM grading systems are based on the presence of esophageal mucosal breaks (erosions or ulcers), in practice such breaks are documented in only a minority of esophageal biopsy specimens taken from patients with reflux esophagitis of any grade.     

Screening for esophagitis and Barrett's esophagus with wireless esophageal capsule endoscopy: a multicenter prospective trial in patients with reflux symptoms

BACKGROUND AND AIM: Esophageal capsule endoscopy (ECE) is a new technology that allows noninvasive investigation of the esophagus. Our aim was to evaluate prospectively the diagnostic yield of ECE in patients with chronic reflux symptoms. PATIENTS AND METHODS: Eighty-nine patients (40 men, mean age 54 yr) referred to five endoscopic centers for esophagogastroduodenoscopy (EGD) were enrolled. Patients first underwent ECE, then EGD; endoscopists who performed the EGD were blind to the ECE data that were interpreted separately by two independent readers. The Los Angeles, Prague, and Montreal classification systems were used to describe endoscopic findings. RESULTS: Seventy-seven patients completed the study. Esophagitis and endoscopically suspected esophageal metaplasia (ESEM) were present in 24 and 10 patients, respectively. Columnar lining was histologically confirmed in seven patients (3 with specialized intestinal metaplasia and 4 with gastric metaplasia). The kappa values for interobserver agreement regarding the diagnosis of esophagitis and ESEM were 0.67 (0.49-0.85) and 0.49 (0.17-0.81), respectively. The diagnostic yields of ECE to detect esophagitis and ESEM were as follows: sensitivity 79% and 60%, specificity 94% and 100%, positive predictive value (PPV) 83% and 100%, negative predictive value (NPV) 92% and 95%, respectively. CONCLUSION: As a screening tool in patients with reflux symptoms, ECE has an excellent specificity and NPV for the diagnosis of esophagitis and ESEM. However, its sensitivity for the diagnosis of ESEM is not optimal. Further studies are necessary to improve the procedure, and to compare the cost-effectiveness of strategies using ECE or EGD.     

Esophagitis in the immunocompromised host: role of esophagoscopy in diagnosis

Thirty episodes of presumed infectious esophagitis in immunocompromised patients were investigated by means of esophagoscopy. Indications for esophagoscopy included dysphagia, odynophagia, and retrosternal pain. Factors potentially predisposing patients to esophagitis included previous exposure to radiation, recent cytotoxic chemotherapy, recent antibiotic therapy, corticosteroid therapy, and neutropenia. Sixteen of the 18 barium esophagograms done before esophagoscopy was performed revealed abnormalities; in 14 cases the results were consistent with infectious esophagitis. Abnormalities were noted during 27 of 30 esophagoscopy procedures. Visual findings were consistent with candidal esophagitis in 18 cases, with viral esophagitis in four, and with both in one. Specific infectious diagnoses were established by culture or histology in 17 episodes: 12 of candidal esophagitis, two of herpes simplex esophagitis, two of concomitant candidal and herpetic esophagitis, and one of enteroviral esophagitis. Specific noninfectious diagnoses were made in two episodes, and the esophagus was found to be normal in three. No specific diagnosis was made in eight episodes although visual examination indicated the presence of esophagitis. The only postesophagoscopy complications recorded were isolated episodes of spiking fever in three patients. In this compromised-host population with presumed infectious esophagitis, esophagoscopy resulted in a rapid and specific infectious diagnosis in 57% of episodes.     

Herpetic Esophagitis: A Diagnostic Challenge in Immunocompromised Patients

Viral esophageal infection is common in immunocompromised patients. Twelve patients with esophagitis secondary to herpes viruses are described. Odynophagia, dysphagia, and gastrointestinal bleeding were the most common symptoms. Multiple infections particularly with candida were present in three of the 12 cases (25%). Typical "volcano ulcers" at endoscopy and discrete diffusely scattered shallow ulcers seen on double contrast esophagram are highly suggestive of herpetic esophagitis. Single contrast esophagram plays no specific role in the diagnosis of herpetic esophagitis. An analysis of clinical, endoscopic, radiological, and pathological features is presented.     

Herpetic esophagitis: a case report on an immunocompetent adolescent

Herpetic esophagitis in immunocompetent individuals is a rare entity that should be suspected clinically by an acute onset of symptoms, and without apparent cause of a symptomatic triad consisting on odynophagia, heartburn and fever. Its occurrence may be due to reactivation of a previous infection or less often a primary infection. Herpes simplex type 1 is the most common cause. Upper endoscopy establishes the diagnosis of suspicion of herpetic esophagitis. It also allows to take multiple biopsy samples and viral culture, leading to a definitive diagnosis. The severity of symptoms is related to the degree of oesophageal involvement. In immunocompromised patients treatment is indicated with acyclovir, but the indication in immunocompetent patients is controversial because the process is time, limited with a low probability of complications. We present a case of acute herpetic esophagitis in an immunocompetent host that debuted acutely with severe upper gastrointestinal tract symptoms, associated with an insidious and nonspecific onset of flu-like symptoms. Endoscopic findings showed a severe involvement in the lower third of the oesophageal mucosa.     

Cytomegalovirus esophagitis in patients with AIDS. A clinical, endoscopic, and pathologic correlation

OBJECTIVE: To examine the clinical presentation, endoscopic features, laboratory diagnosis, and outcome of cytomegalovirus esophagitis in patients with the acquired immunodeficiency syndrome (AIDS). DESIGN: Retrospective review of endoscopy records and esophageal biopsy material from patients with AIDS during the 24-month period from 1986 to 1988. SETTING: Urban medical center, central receiving county hospital. PARTICIPANTS: Sixteen inpatients or outpatients seen by gastroenterology consultants at a single hospital. INTERVENTIONS: Endoscopy with multiple mucosal biopsies and viral culture of all esophageal mucosal lesions. Proven or suspected cyclomegalovirus disease was verified in patients using immunohistochemical antibody staining of mucosal biopsy specimens. MEASUREMENTS AND MAIN RESULTS: Odynophagia was the most prominent esophageal symptom, seen in 14 of 16 patients with cytomegalovirus esophagitis confirmed by immunohistochemical staining. Ulcerations of the esophagus were identified in all but 1 patient and typically appeared as large, solitary, shallow lesions. Routine hematoxylin and eosin staining of esophageal mucosal and submucosal specimens showed intranuclear inclusions in all patients, whereas cytomegalovirus culture was positive in only 8 of 14 patients. Cytomegalovirus esophagitis was associated with a poor long-term prognosis. CONCLUSION: Cytomegalovirus esophagitis in patients with AIDS is a well-defined entity with characteristic clinical symptoms and endoscopic findings, as well as histopathologic abnormalities.     

Herpesvirus infection of the esophagus and other visceral organs in adults. Incidence and clinical significance.

An autopsy review covering a 10 year period revealed 56 adult patients with histocytologic evidence of herpesvirus (herpes simplex or varicella-zoster) infection involving nongenital viscera. Review of the clinical records of these patients disclosed that herpesvirus infections were clinically suspected in only seven of them: three patients with cutaneous herpes zoster, two patients with herpetic keratitis and two patients with gingivostomatitis. Nine additional patients also had ulcerative gingivostomatitis, but this was attributed to either fungal organisms or chemotherapy. Forty patients showed no apparent clinical signs or symptoms of herpetic infection. Visceral involvement was not suspected clinically in any of the 56 patients. The most common underlying disease process afflicting these patients was a malignant neoplasm, usually involving the hematopoietic or lymphoreticular systems, but almost one-third had a variety of nonmalignant diseases. The presence of an associated infectious process involving bacterial, fungal or protozoal organisms, or additional viral agents, was confirmed by culture studies or autopsy microscopic findings in all but two patients. The viscus most commonly involved by herpetic infection was the esophagus. Herpetic esophageal ulcers were found in 50 cases, and in 41 cases no other organs appeared involved. Because esophageal ulcers are usually asymptomatic, antemortem diagnosis is extremely difficult. The data derived from this and previous studies indicate that herpetic ulcers frequently become secondarily infected with bacteria and/or fungi and that the greatest clinical significance of these ulcers is as a site of secondary infection, particularly in patients who have undergone immunosuppression (immunosuppressed patients). The advent of effective antiherpesvirus drugs and greater clinical awareness of the disease should serve as a stimulus to establish a clinical diagnosis of visceral herpesvirus infection more frequently.     

Esophagitis in patients with acquired human immunodeficiency syndrome: an histological and immunohistochemistry study

BACKGROUND: Almost all patients with acquired immunodeficiency virus syndrome will have gastrointestinal symptoms during the course of their illness. The high prevalence and complications of esophagitis are well documented. AIM: Graduate esophagitis; identify microorganisms like Candida sp, cytomegalovirus, herpesvirus and mycobacteria; identify by immunohistochemical staining viral agents cytomegalovirus, herpesvirus I, herpesvirus II, Epstein-Barr Virus, human papilloma virus and human immunodeficiency virus; verify how immunohistochemistry changes the profile of esophagitis; verify the association between the histological and endoscopical findings; verify the relevance of the number of fragments studied in the characterization of the histological agents. METHODS: We studied retrospectively esophageal biopsies in 227 patients with acquired immunodeficiency virus syndrome using hematoxylin and eosin, PAS (periodic acid of Schiff), Groccott and Ziehl-Nielsen stains and immunoperoxidase stains to detect opportunistic agents. Endoscopic aspects were studied. RESULTS: The non-specific esophagitis grade III, in the inferior third of the esophagus, was the most frequent type. Candida sp was the most frequent agent, followed by viruses cytomegalovirus, herpesvirus and mycobacteria. The presence of plaque and ulceration suggested the diagnosis of esophageal candidiasis and cytomegalovirus esophagitis. Immunohistochemical allowed the characterization of cytomegalovirus and of herpesvirus in those cases where other techniques could not achieve it, furthermore the cytomegalovirus was also found in histological normal cases, making the use of this technique advisable in routine diagnosis. The herpesvirus I was not found isolated but associated to herpesvirus II. We have not found immunoreactivity for the Epstein-Barr virus and the human immunodeficiency virus. The number of fragments does not seem to influence the detection of the etiologic agent. CONCLUSION: The endoscopic findings of plaques or ulcers are associated with candidiasis or cytomegalovirus esophagitis. Immunohistochemisty improved the diagnosis of viral infections. It is possible to detect cytomegalovirus infections in endoscopic and histologic normal cases.     

The causes of esophageal symptoms in human immunodeficiency virus infection. A prospective study of 110 patients.

STUDY OBJECTIVES.--To determine the prevalence of infectious agents in patients with human immunodeficiency virus infection and odynophagia or dysphagia; the utility of endoscopic, histologic, cytologic, and virologic testing for the diagnosis of esophagitis; and the yield of blind brushings of the esophagus in this setting. DESIGN.--Prospective clinical case study. SETTING.--Urban county hospital. PATIENTS.--One hundred ten consecutive patients with esophageal symptoms and documented human immunodeficiency virus infection. INTERVENTION.--Blind brushing of the esophagus via orogastric tube followed by endoscopy with esophageal brushing for fungal stain, Papanicolau smear, and viral cultures and esophageal biopsies for histologic examination and viral culture. MAIN RESULTS.--Seventy-two (65%) of the 110 patients had a total of 100 esophageal infections. Thirty-three (30%) had Candida alone, 22 (20%) had Candida and cytomegalovirus, two (1.8%) had Candida with cytomegalovirus and herpes simplex virus, seven (6%) had cytomegalovirus alone, six (5%) had herpes simplex virus alone, and two (1.8%) had both viruses. Fifty of 55 patients with plaques alone had Candida, and two (4%) had only viral infection. Of 19 patients with erosions or ulcers, 11 (58%) had a viral infection, two (11%) had Candida alone, and six (30%) had no etiologic agent identified. The sensitivity of endoscopic brushings (95%) was better than that of histologic examination (70%) in the diagnosis of Candida esophagitis. Likewise, viral cultures of brushings or biopsy specimens were more sensitive (67%) than histologic examination (35%) for viral esophagitis. Blind brushing of the esophagus had a sensitivity and specificity for infectious esophagitis of 84% and 75%, respectively. Oral thrush had a sensitivity of 53% and a positive predictive value of 77% for Candida esophagitis.     

Case report: Complete esophageal obliteration secondary to cytomegalovirus in AIDS patient

HIV‐related benign esophageal strictures have been reported secondary to idiopathic esophageal ulceration, cytomegalovirus (CMV) esophagitis, herpetic esophagitis, and increased sensitivity to radiation therapy. Despite extensive and deep nature of CMV ulceration, stricture formation is uncommon. There have been anecdotal reports of esophageal strictures secondary to CMV infection in HIV patients. Esophageal stricture has been reported during active CMV ulceration as well as subsequent to successful treatment. Esophageal strictures secondary to CMV have also been reported without prior ulceration. We report a patient with CMV esophagitis presenting with ulceration and stricture who developed total obliteration of esophageal lumen following treatment with gancyclovir.