Sepsis and hepatitis caused by Herpes Simplex esophagitis in an immunocompetent adult

Introduction: The differenzial diagnosis of fever is generally laborious. We present a case in which the etiology of fever was revealed by endoscopy and histology. Patient: A 55-year-old male, a veterinary researcher working on mice, presented with a 4-day history of fever, dysphagia, odynophagia, vomiting and black stools. The past history included plastic surgery of the mitral valves and hepatitis of unknown etiology in the 1990s. He denied abuse of tobacco or alcohol. His temperature was 39°C; but the physical examination was otherwise unremarkable. Blood investigations revealed elevated liver necroenzymes, an impaired renal function, netropenia, thrombopenia and hypoalbuminemia. The chest X-ray was normal. Abdominal ultrasonography demonstrated gallbladder stones. Echocardiography did not indicate valve vegetation. Esophagogastroduodenoscopy revealed multiple round ulcerations throughout the esophagus. Histological examination identified acute, severe inflammation and ulceration, with no evidence of malignancy or Crohn's disease. Positive staining of a specific antibody against herpes simplex viruses (HSV) was seen in the nuclei of esophageal epithelial cells. Subsequent polymerase chain reaction confirmed HSV type 1 infection. The serum HSV IgM was elevated, while the IgG was normal. The results of HIV serology, immunoglobulin quantitation and T-cell studies, including CD4 lymphocytes, were all normal. HbsAg and a-HCV were both negative. Treatment of the patient with intravenous acyclovir for 7 days (5mg/kg every 8h) resulted in marked clinical, laboratory and endoscopic improvement within a week.

Conclusions: HSV esophagitis may be complicated by sepsis, hepatitis, renal failure and neutropenia, even in an immunocompetent patient, but can be diagnosed via the characteristic endoscopic findings.

This work was partly supported by the TÁMOP-4.2.1./B-09/1/KONV.