Herpes simplex esophagitis presenting as acute necrotizing esophagitis (“black esophagus”) in an immunocompetent patient

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“Black esophagus” is a rare condition which is defined as a dark pigmentation of the esophagus seen during endoscopy, associated with histologic mucosal necrosis. We report a case of proven herpes simplex esophagitis causing black esophagus in an immunocompetent patient. A 54-year-old man with a history of well-controlled schizophrenia and living in an assisted-living facility for the mentally ill was admitted to the hospital because of coffee-ground emesis and melena. The patient was hemodynamically stable on initial evaluation. His hematocrit dropped from 43 % to 33 % in 12 h. Emergency upper endoscopy showed grade D esophagitis with blackish discoloration of the mucosa, mainly affecting the lower third of the esophagus ([Fig. 1]). Esophageal biopsy showed multinucleated giant cells with Cowdry type A intranuclear inclusion bodies in epithelial cells, characteristic of herpes esophagitis ([Fig. 2]). Serologic testing (IgG antibodies) for herpes simplex virus 1 was positive. The patient was treated with intravenous fluid therapy, sucralfate by mouth, and intravenous esomeprazole 40 mg twice a day. Repeat upper endoscopy after 1 week showed healing of the mucosa except for a few tiny superficial ulcers in the esophagus ([Fig. 3]).

Fig. 1 a, b Endoscopic images showing “black esophagus” (necrotizing esophagitis).

Fig. 2 High-power photomicrograph showing multinucleated giant cells with intranuclear inclusion bodies, typical of herpes esophagitis.

Fig. 3 Repeat esophagoscopy showed disappearance of the black lesions.

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