S5038 From Lips to Lumen: A Curious Case of Herpetic Esophagogastritis

Introduction: Herpes simplex virus (HSV-1), commonly recognized as a culprit for sexually transmitted infections, is an uncommon cause of peptic ulcer disease, particularly in immunocompetent people. It clinically presents as postprandial epigastric pain, nausea, vomiting, anemia, and hematochezia. This case report describes a HSV-1-related esophagogasritis in a patient with a vague presentation. Case Description/Methods: A 64-year-old man with a history of hypertension presented with diarrhea consisting of 2-3 daily episodes of loose watery, easy to flush stools over the past 2 months with associated weight loss and desquamative rash on palms, elbows, feet, knees, and face. No history of abdominal pain, nausea or vomiting, fever, chills, change in appetite, melena, or hematochezia was reported. The admission vitals, abdominal examination and computed tomography (CT) imaging were unremarkable. Labs were notable for microcytic anemia with mild leukocytosis. Calculated stool gap of 36 was concerning for secretary diarrhea with a negative HIV test, Celiac panel and stool studies. Pancreatic elastase levels were low and the patient was initiated on oral pancreatic enzyme supplementation for suspected moderate pancreatic insufficiency. Later in the hospital course, the patient developed intermittent fever and mild icterus with a distended abdomen. Repeat CT abdomen confirmed hepatosplenomegaly with retroperitoneal lymph node enlargement. Given ongoing diarrhea, he underwent an upper gastrointestinal (GI) endoscopy with biopsy which showed necrotic debris with atypical cells containing herpetic-type inclusions involving gastric fundus and body. Discussion: Few studies in the past have shown association between HSV-1 and esophagitis or gastritis. HSV-1 esophagitis with concomitant duodenitis in a healthy individual is, however, rare as seen in our case. It is typically confirmed with endoscopic biopsy, histopathology and immnohistochemistry to rule out other etiology including Helicobacter pylori gastritis which was negative in our patient. Management is often conservative with repeat endoscopy to ensure complete healing. The patient was discharged on oral valacyclovir 1 g twice daily prescribed for 10 days with pantoprazole twice daily for 4 weeks and sucralfate 1 g 4 times daily for 2 weeks. This case emphasizes the significance of considering HSV-1 infection as one of the differential diagnoses when approaching a patient with similar GI symptoms.