Herpes simplex virus esophagitis in immunocompetent patients: a case report and updated literature review

Introduction: Herpes simplex virus (HSV) esophagitis in immunocompetent individuals is a rare occurrence, albeit it being a self-limiting disease. Case presentation: We describe a case of HSV esophagitis in a 49-year-old female immunocompetent patient who presented with dysphagia, odynophagia, and fever. Upper gastrointestinal endoscopy revealed ulcerative esophagitis in the mid to distal esophagus. Histopathology and immunohistochemistry were positive for HSV, and the patient was treated with intravenous acyclovir and a high-dose proton pump inhibitor. Repeat endoscopy at 2 months showed marked improvement in esophageal ulceration. Discussion: The incidence of HSV esophagitis still remains poorly documented in the literature, given its self-limiting nature and postulated pathogenesis. We performed a comprehensive literature review aiming to identify clinical and endoscopic features, diagnostic methods, treatment, and outcomes of HSV esophagitis spanning over the last decade, from 2009 to the present. Histopathology was predominantly used in 34/41 (82.9%) of cases for diagnostic confirmation and was often employed in conjunction with immunohistochemistry or polymerase chain reaction. There is limited evidence regarding the use of antivirals in this setting, yet 34/41 (82.9%) of patients still received antiviral therapy. No complications were reported in the majority of cases; however, there were two cases of esophgeal perforation, three cases of eosinophilic esophagitis, and two cases of recurrence documented. Conclusion: Despite HSV esophagitis being a self-limiting disease, early endoscopic examination and biopsy may be beneficial in assisting the early initiation of antivirals where indicated, thereby preventing serious complications.