S4309 Intersecting Pathologies: Herpes Simplex Esophagitis and Eosinophilic Esophagitis

Introduction: Herpes Simplex Esophagitis (HSE) is a viral infection of the esophagus caused primarily by HSV-1, typically affecting immunocompromised individuals. It presents with symptoms such as odynophagia, dysphagia, and chest pain, and is diagnosed through endoscopy and histopathology revealing multinucleated giant cells with intranuclear inclusions. Conversely, Eosinophilic Esophagitis (EoE) is a chronic, immune-mediated condition marked by eosinophilic infiltration of the esophageal mucosa, often associated with atopic diseases. Though both conditions are independently recognized causes of esophagitis, recent literature suggests a potential association between them, even in immunocompetent patients. Epithelial disruption in EoE may predispose the esophagus to viral infection, while HSE could provoke eosinophilic inflammation. This report explores the rare coexistence of HSE and EoE in an immunocompetent individual. Case Description/Methods: An 18-year-old man with a history of asthma presented with odynophagia, dysphagia to solids, and occasional acid reflux. He reported a history of childhood food allergies, with current milk allergy being the only persistent one. No prior esophageal evaluations were noted, and family history was noncontributory. Initial treatment with an 8-week proton pump inhibitor and a 5-day steroid course led to symptom relief. An esophagogastroduodenoscopy showed LA Grade B reflux esophagitis. Histopathological examination of biopsies revealed findings consistent with both HSE and EoE. Treatment was initiated with antiviral therapy for HSE, followed by plans for EoE management. Discussion: This case highlights the diagnostic and therapeutic complexity of concurrent HSE and EoE in an immunocompetent host. Shared symptoms such as dysphagia and odynophagia can obscure the dual pathology. Accurate diagnosis requires careful endoscopic and histological evaluation to distinguish HSE's viral cytopathic changes from EoE's eosinophilic inflammation. The sequence of therapeutic interventions is critical, with viral management typically prioritized. This dual presentation underscores the importance of considering coexisting etiologies in esophagitis and may prompt further investigation into the bidirectional relationship between viral infection and eosinophilic inflammation. Heightened awareness and additional research may enhance diagnostic accuracy and therapeutic outcomes in similar complex presentations.