S4419 Herpes Simply Strikes Back: A Case of Esophagitis in the Immunocompetent

Introduction: Herpes simplex virus (HSV) esophagitis is clinically significant and presents with nonspecific symptoms (dysphagia, odynophagia) which can lead to delayed diagnosis. HSV esophagitis is typically seen in the immunocompromised population, and rarely seen in immunocompetent individuals. Herein we present a rare case of recurrent HSV esophagitis in an immunocompetent man. Case Description/Methods: A 32-year-old man with a past medical history of seizure disorder, and previous incompletely treated HSV esophagitis presented to the emergency department with multiple concerning symptoms. He reported nausea, small volume hematemesis, odynophagia, and sharp right upper quadrant abdominal pain. Initial evaluation showed that his vital signs were HR 82, BP 152/101, Temp 36.5°C, and labs were significant for elevated WBC 21,500, Hgb 18.2 g/dl, and impaired renal function (creatinine 1.7). Computed tomography abdomen and pelvis demonstrated thickening of the distal esophageal wall. Subsequent upper endoscopy revealed severe herpetiform esophagitis with no signs of active bleeding. Biopsies were taken confirming the diagnosis of HSV esophagitis. The patient was initiated on a course of high dose valacyclovir, with arrangements made for close outpatient follow-up and repeat endoscopic evaluation. Discussion: HSV esophagitis is estimated to represent <1% of all infectious esophagitis cases in immunocompetent individuals. This case demonstrates a rare presentation of recurrent HSV esophagitis in an immunocompetent individual. It highlights the importance of early recognition of HSV esophagitis, the recurrence in immunocompetent individuals, along with the importance of the patients’ education and follow-up.