S4453 HSV Esophagitis Presenting With Upper GI Bleeding in an Immunocompetent Patient: A Case Report

Introduction: Herpes simplex virus (HSV) esophagitis is a viral inflammation of the esophagus, predominantly caused by HSV-1. It is commonly associated with immunocompromised states, including HIV/AIDS, malignancies, or immunosuppressive therapy. However, it has also been reported in immunocompetent or elderly individuals. Typical symptoms include odynophagia, dysphagia, and retrosternal pain, though elderly or cognitively impaired patients may present atypically. We present a case of microcytic anemia caused by HSV esophagitis. Diagnosis relies on biopsy with histopathologic features such as multinucleated giant cells and Cowdry type A inclusions, as well as PCR or immunohistochemical confirmation. Gastrointestinal (GI) bleeding is a recognized but uncommon complication. In such cases, normocytic anemia may reflect either acute blood loss or anemia of chronic disease—especially in elderly patients with comorbidities like heart failure or chronic inflammation. This highlights the importance of considering HSV esophagitis in elderly patients presenting with unexplained anemia or melena, even in the absence of overt immunosuppression. Case Description/Methods: An 82-year-old woman with a history of atrial fibrillation on anticoagulation, heart failure with reduced ejection fraction, and prior peptic ulcer disease presented after a fall. She endorsed melena for two weeks prior. Initial lab work revealed normocytic anemia with hemoglobin 4.3 g/dL. She received two units of packed red blood cells and was started on proton pump inhibitor therapy. Given her prior GI history, she underwent esophagogastroduodenoscopy, which showed ulcerative esophagitis. Biopsy revealed acute inflammation and cellular changes consistent with HSV infection, positive for HSV-1/2. The patient was treated with acyclovir 500 mg for 14 days, resulting in clinical improvement. Discussion: This case shows the importance of maintaining a broad differential diagnosis in elderly patients with upper GI bleeding, especially those on anticoagulation. Although peptic ulcer disease was initially suspected, biopsy confirmed HSV esophagitis as the bleeding source despite the patient being immunocompetent. It has only been reported that 5.3% with HSV esophagitis are immunocompetent and will present with Upper GI bleeding. Early endoscopy and histologic confirmation enabled appropriate treatment. HSV esophagitis should be considered in high-risk patients, even without clear immunosuppression to prevent complications such as bleeding, stricture, or perforation.