Abdominal MichaelJ.
Shortsleeve,
Herpes
MD
authors
all
the clinical
T
and
presented
with
onset
of
acute odynophagia after a flulike prodrome of fever, sore throat, or myalgias. trast
In all five patients, double-conesophagograms revealed
innumerable of ulceration, in the
punctate or linear areas predominantly located
midesophagus
the left
main
near
bronchus.
the
Four
level
of
patients
received viscous lidocaine and antacids, and one patient, intravenously administered acycbovir. All five patients had an acute, self-limited illness with complete resolution of symptoms 10-12 days from the time
of presentation.
It is concluded
that,
if the characteristic clinical prodrome is present in patients with typical findings on double-contrast esophagograms, such patients can receive conservative treatment without need
for endoscopic Index
intervention.
terms:
simplex,
Esophagitis,
713.291
Herpes
#{149}
Healthy
Radiographic
and
findings in five othermale patients with herwho had no underlyproblems. The
Findings’
HE herpes
simplex virus has been recognized as a relatively common opportunistic invader of the esophagus in immunocompromised patients. However, it has been well documented in the medical literature that herpes esophagitis may occasionally occur as an acute, self-limited illness in otherwise healthy individuals who have no underlying immunologic problems (1-8). One of the authors (M.S.L.) previously reported the radiographic findings in such a patient in whom double-contrast esophagography revealed innumerable tiny ulcers in the esophagus (9). Since then, we have examined four other immunocompetent patients with herpes esophagitis. The findings at examination with double-contrast esophagography are so characteristic in these cases that we believe it is possible to diagnose herpes esophagitis with radiographs in immunocompetent patients without need for endoscopy. A complete description of the clinical and radiographic features of this condition is therefore provided herein.
713.206
Radiology
1992;
182:859-861
MATERIALS
AND
METHODS
Since 1981, we have examined five otherwise healthy patients with herpes esophagitis in whom double-contrast esophagograms were obtained. The presence of herpes esophagitis was confirmed by means brushings, tients
From the Department of Radiology, Mount Auburn Hospital, 330 Mt Auburn St. Cambridge, MA 02238 (MiS.); and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.S.L.). Received September 9, 1991; revision requested October 8; revision received November 4; accepted November 7. Ad-
dress
reprint
( RSNA,
requests 1992
to M.J.S.
of endoscopic biopsy samples, and/or cultures in three pa-
and
elevated
serum
titers
for
herpes
simplex virus antibodies in one patient. The other patient was treated for herpes esophagitis on the basis of the clinical and radiographic findings without endoscopic or serologic confirmation. These five cases accounted for about 10% of all cases of herpes esophagitis diagnosed with radiography during this period at our institutions. The double-contrast esophagograms from these five patients were reviewed retrospectively to determine the radiographic
Radiology
MD
In Otherwise
Clinical
report
radiographic wise healthy pes esophagitis ing immunologic patients
S. Levine,
Esophagitis
Patients: The
Marc
#{149}
Gastrointestinal
and
findings.
logic records related with
Endoscopic
were also the barium
reviewed studies.
and
medical records mine the clinical and subsequent
were reviewed presentation, patient course.
to detertreatment,
RESULTS Clinical
Findings
The five patients with herpes esophagitis were male subjects aged 15-23 years who had previously been healthy. All had acute onset of odynophagia for 1-3 days before they sought medical attention. Their odynophagia was characterized by severe substernal chest pain during swallowing. All five patients had a flulike syndrome with fever, sore throat, or myalgias for 3-7 days prior to the development of odynophagia. Two patients had associated ulcers on the lips or buccal mucosa at the time of presentation. One patient indicated that his girlfriend had had “sores” on her lips several weeks before his initial examination. All patients denied taking any oral medications known to cause esophagitis.
Radiographic
Findings
In all five patients, double-contrast esophagograms revealed similar findings, with multiple tiny ulcers 2-S mm in
diameter
(Figs
1, 2, 3a).
The
shallow
areas of ulceration appeared as punctate collections or linear streaks of barium on the mucosa that were too numerous to count. The ulcers tended to be clustered in the middle third of the esophagus,
near
the
level
of the
left
main bronchus, but also extended into the distal third of the esophagus. The ulcers tended to have a linear alignment along the long axis of the esophagus. None of the patients had evidence of a hiatal hernia or spontaneous gastroesophageal reflux at fluoroscopy.
patho-
and corFinally,
Abbreviation: ciency
AIDS
=
acquired
immunodefi-
syndrome.
859
Endoscopic
and
Pathologic
Findings Three patients underwent endoscopy within several days of the radiobogic examination. In all three patients, endoscopic
findings
of
multiple
in
the
confirmed
the
ulcers,
predominantly
tiny
middle
third
of
the
3b). revealed
In one patient, multiple small
spersed
with
(Fig
tients
had
the
presence
esophagus
endoscopy vesicles
ulcers.
All
intranuclear
also inter-
three
pa-
inclusions
on
endoscopic brushings or biopsy samples and/or findings positive for the herpes simplex virus on viral cultures. The two other patients did not undergo endoscopy.
However,
tients
had
pes and
one
of these
elevated
two
serum
pa-
titers
for
her-
simplex antibodies during the convalescent stages, a finding
indicated
herpetic
patient
had
findings
infection.
The
characteristic
and
the
acute that other
radiographic
associated
clinical
pro-
drome; hence, on the basis of previous experience with this condition, he was treated for herpes esophagitis without endoscopic
or
Treatment
and
Four
patients
treatment
with
antacids.
All
clinical
serologic
confirmation.
Patient received viscous
four
lidocaine
received day)
gradual
with
complete
10-12
The
patient,
other
acycbovir
(375
intravenously clinical
hours of the
and had treatment
symptoms
days
mg,
for
striking
and
experienced
of symptoms
presentation.
1.
after
who
three
times
10 days,
had
within
24
response
a
resolved, underwent
study
or endoscopy.
none
of
follow-up
the
1, 2.
(1) Double-contrast
has
pa-
barium
been
well
wise
healthy,
jects
who
documented
are
simplex
The
DISCUSSION
in
virus
type
exposed
virus
core
virus that is found in the salivary glands and secreted in the saliva in about 2% of healthy adults without
or
symptoms
(10).
between infected
subjects may develop
matitis
or
who tern,
virus
who
are herpes
phanyngitis
(1).
have a compromised however, exposure
may
lead
to
patients
herpes malignancy;
treatment
illness; roids,
or
cently,
esophagitis
with
chemotherapy; acquired
esophagitis
860
of
are
#{149} Radiology
gia of
debilitating
ste-
or,
resyn-
of these
the
may
be
otherwise
patient
as an
ways
occurs
ness,
and
after
presentation
these
symptoms
patients
conservatively
with
immunocompromised,
herpes
(viscous
patient
with
herpes
it
acids.
Occasionally,
my-
by
the
to seek
medical
the
odynopha-
herpes
esophagitis
subjects
almost
acute,
atin al-
self-limited As can
topical
3-14
illdays
a result, be
anesthetics and
however,
patients
ant-
severe
odynophagia
without
endoscopy.
is performed, esophagitis
the can
also
If endos-
diagnosis be
of
her-
confirmed
samples.
Although the radiographic findings have been described only anecdotally in the radiology literature (9), our experience indicates that otherwise healthy patients with herpes esophagitis have remarkably similar findings on doublecontrast esophagograms. All of our patients had innumerable punctate or binear areas of ulceration, predominantly located in the midesophagus near the level of the left main bronchus (Figs 1-3).
treated
analgesics,
particularly
with positive viral cultures, direct immunofluorescent staining for the herpes simplex antigen, or demonstration of intranuclear inclusions on brushings or biopsy
which
(1-5). with
lidocaine),
a
(1,2,5-
resolve
usually
have
infection,
Although severe,
lesions
conditions is followed
healthy
pes
lasts 3-10 days by fever, sore
odynophagia,
(1-8).
copy
(2,5,6,8). patients
respiratory
all
prompts
are
these
that
of acute
tention
because
most
healthy
require antiviral drugs such as acyto accelerate healing of the herlesions and alleviate symptoms. titers for herpes simplex virus 1 can be obtained during the acute convalescent stages to confirm the
diagnosis
of esophageal
of
prodrome
onset
all
immunodeficiency
drome (AIDS) (11-14). Although most patients
7). This
herpetic
development
upper or
male
They exposure
mucosa
is characterized
algias,
radiation,
the
prodrome
throat,
almost
immunosuppressed
underlying
and
patients
infection
As a result,
with
clinically
to the
with
most
flulike
immune systo the virus
opportunistic
esophagus.
to
are
(2-7).
of recent
or buccal
symptoms,
(1-8).
usually years
a history
lips
develop
is characteristic
15-30
partners
the
Prior
with
exposed gingivostoIn
have
may cbovir petic Serum type and
associated
pharyngitis
who
aged
to sexual on
is transmitted
patients by direct contact oral secretions. Otherwise
healthy virus
the
The
otherwise
with
herpes
without
presentation patients,
often
the
occasionally or
clinical these
other-
sub-
to
may with
subjects
1 is a DNA
that
immunocompetent
esophagitis
simplex
from
esophagitis, manifested by innumerable punctate and linear areas of ulceration in the midesophagus near the level of the left main bronchus. This patient’s case was reported previously by one of the authors (M.S.L.) (9). (2) Double-contrast esophagogram from another immunocompetent patient with herpes esophagitis, manifested by multiple tiny ulcers with linear arrangement in the midesophagus. Note that radiographic findings are remarkably similar to those in 1.
gingivostomatitis
Herpes
esophagogram
a
no symptoms by the end period. Because their
tients
2.
Figures
conservative
improvement,
resolution
Course
Herpes
esophagitis
in
immuno-
compromised patients is also characterized by ulceration, but such patients tend to have discrete, more widely separated ulcers that are larger and less
March
1992
esophagitis by means of the clinical history and presentation. In summary, herpes esophagitis may occasionally occur in otherwise healthy patients
as
an
acute,
self-limited
illness
manifested by multiple tiny ulcers that are predominantly located in the midesophagus near the level of the left main bronchus. If the characteristic dinical prodrome is present in patients with typical findings on double-contrast esophagograms, these individuals can undergo conservative treatment without need for endoscopic intervenlion. U
References 1.
Depew WT, Prentice RS, Beck IT, Blakeman LR. Herpes simplex ulcerative esophagitis in a healthy subject. Am J Gastroenterol 1977; 68:381-385. Owensb’ LC, Stammer JL. Esophagitis assoriated with herpes simplex infection in an immunocompetent host. Gastroenterology 1978; 74:1305-1306. Springer DJ, DaCosta LR, Beck IT. A syndrome of acute self-limiting ulcerative esophagitis in young adults probably due to herpes simplex virus.Dig Dis Sci 1979; 24:535-539. Solammadevi SV, Patwardhan R. Herpes esophagitis. Am J Gastroenterol 1982; 77:48-50. Deshmukh M, Shah R, McCallum RW. Experience with herpes esophagus in otherwise healthy patients. Am J Gastroenterol 1984; 79:173-176. DiPalma JA, Brady CE. Herpes simplex esophagitis in a nonimmunocompromised host with gastroesophageal reflux. Gastrointest Endosc 1984; 30:24-25. Desigan G, Schneider RP. Herpes simplex esophagitis in healthy adults. South Med 1985; 78:1135-1137. Ginaldi 5, Burgert W, Paulk HT. Herpes esophagitis in immunocompetent patients. Am Fam Physician 1987; 36:160-164. DeGaeta L, Levine MS. Guglielmi GE, Raffensperger EC, Laufer I. Herpes esophagitis in an otherwise healthy patient. AiR 1985; 144:1205-1206. Douglas RG, Couch RB. A prospective study of chronic herpes simplex virus infection and recurrent herpes libialis in humans. J Immunol 1970; 104:289-295. Berg JW. Esophageal herpes: a complication of cancer therapy. Cancer 1955; 8:731-740. Rosen P, Hajdu SI. Visceral herpes virus inlections in patients with cancer. Am J Clin Pathol 1971; 56:459-465. Nash G, Ross JS. Herpetic esophagitis: a common cause of esophageal ulceration. Hum Pathol 1974; 5:339-345. Levine MS, Woldenberg R, HerlinFer H, Laufer I. Opportunistic esophagitis in AIDS: radiographic diagnosis. Radiology 1987; 165: 815-820. Levine MS, Laufer I, Kressel HY, Friedman HM. Herpes esophagitis. AJR 1981; 136:863-
JM, DaCosta
2.
3.
4. 5.
6.
7. 4. Double-contrast esophagogram from an immunocompromised patient with herpes esophagitis, manifested by discrete
8.
ulcers seen en face (black arrows) and file (white arrow) in the midesophagus. that ulcers are larger and less numerous
in proNote and
9.
are more
in im-
10.
widely
munocompetent
separated
than
patients
with
those this
disease. II
Figure
3.
Radiographic
and
endoscopic
cor-
relation in another immunocompetent patient with herpes esophagitis. (a) Doublecontrast esophagogram shows multiple punctate ulcers in the midesophagus. Although findings are more subtle in this case, note the similarity to Figures 1 and 2. (b) Endoscopic photograph shows cluster of tiny ulcers (arrows) in midesophagus.
numerous (Fig 4) (14-17). of the ulcers in otherwise jects
with
herpes
The small size healthy sub-
esophagitis
may
be
related to an intact immune system that contains the herpetic infection and prevents the ulcers from enlarging. In any case, pes by
our
experience
esophagitis
suggests tends
different
radiographic
immunocompromised competent patients. Other conditions ated
Volume
with
superficial
182
#{149} Number
that
to be
findings
and
ulceration
3
in
immunoalso
may
her-
manifested
be associin
the
esophagus. Oral medications such as tetracycline and doxycycline may cause a focal contact esophagitis manifested by multiple shallow ulcers in the midesophagus that are indistinguishabbe from those of herpes esophagitis
(18,19).
However,
a temporal
Radiation
esophagitis,
ulceration,
ally
can
but
be differentiated
these
conditions
from
13. 14.
15. 16. 17.
18.
19.
20.
caustic
esophagitis, and, rarely, esophageal involvement by Crohn disease or Beh#{231}et disease may be associated with superficial
12.
relation-
ship between ingestion of the offending medication and the onset of esophagitis should suggest the correct diagnosis. Reflux esophagitis is a more common cause of ulceration but tends to affect the distal esophagus and is usually associated with a hiatal hernia or gastroesophageal reflux. Recently, cytomegalovirus and human immunodeficiency virus have been identified as other causes of ulceration, but these infections occur primarily in patients with AIDS and are often manifested by giant, relatively flat ulcers in the esophagus
(14,20,21).
.
21.
Shortsleeve MJ, Gauvin GP, Gardner RC, Greenberg MS. Herpetic esophagitis. Radiology 1981; 141:611-617. Levine MS. Loevner LA, Saul SH, Rubesin SE, Herlinger H, Laufer I. Herpes esophagitis: sensitivity of double-contrast esophagography. AIR 1988; 151:57-62. Creteur V. Laufer I, Kressel HY, et al. Druginduced esophagitis detected by double-cona8st radiography. Radiology 1983; 147:365-. Bova JG, Dutton NE, Goldstein HM, Hoberman U. Medication-induced esophagitis: diagnosis by double-contrast esophagography. AJR 1987; 148:731-732. Balthazar EJ, Megibow AJ, Hulnick D, Cho KC, Berenbaum E. Cytomegalovirus esophagitis in AIDS: radiographic features in 16 patients. AJR 1987; 149:19-923. Levine MS. Loercher C, Katzka DA, Herlinger H, Rubesin SE, Laufer I. Giant, human immunodeficiency virus-related ulcers in the esophagus. Radiology 1991; 180:323-326.
usu-
herpes
Radiology
#{149} 861
Shortsleeve,
Herpes
MD
authors
all
the clinical
T
and
presented
with
onset
of
acute odynophagia after a flulike prodrome of fever, sore throat, or myalgias. trast
In all five patients, double-conesophagograms revealed
innumerable of ulceration, in the
punctate or linear areas predominantly located
midesophagus
the left
main
near
bronchus.
the
Four
level
of
patients
received viscous lidocaine and antacids, and one patient, intravenously administered acycbovir. All five patients had an acute, self-limited illness with complete resolution of symptoms 10-12 days from the time
of presentation.
It is concluded
that,
if the characteristic clinical prodrome is present in patients with typical findings on double-contrast esophagograms, such patients can receive conservative treatment without need
for endoscopic Index
intervention.
terms:
simplex,
Esophagitis,
713.291
Herpes
#{149}
Healthy
Radiographic
and
findings in five othermale patients with herwho had no underlyproblems. The
Findings’
HE herpes
simplex virus has been recognized as a relatively common opportunistic invader of the esophagus in immunocompromised patients. However, it has been well documented in the medical literature that herpes esophagitis may occasionally occur as an acute, self-limited illness in otherwise healthy individuals who have no underlying immunologic problems (1-8). One of the authors (M.S.L.) previously reported the radiographic findings in such a patient in whom double-contrast esophagography revealed innumerable tiny ulcers in the esophagus (9). Since then, we have examined four other immunocompetent patients with herpes esophagitis. The findings at examination with double-contrast esophagography are so characteristic in these cases that we believe it is possible to diagnose herpes esophagitis with radiographs in immunocompetent patients without need for endoscopy. A complete description of the clinical and radiographic features of this condition is therefore provided herein.
713.206
Radiology
1992;
182:859-861
MATERIALS
AND
METHODS
Since 1981, we have examined five otherwise healthy patients with herpes esophagitis in whom double-contrast esophagograms were obtained. The presence of herpes esophagitis was confirmed by means brushings, tients
From the Department of Radiology, Mount Auburn Hospital, 330 Mt Auburn St. Cambridge, MA 02238 (MiS.); and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.S.L.). Received September 9, 1991; revision requested October 8; revision received November 4; accepted November 7. Ad-
dress
reprint
( RSNA,
requests 1992
to M.J.S.
of endoscopic biopsy samples, and/or cultures in three pa-
and
elevated
serum
titers
for
herpes
simplex virus antibodies in one patient. The other patient was treated for herpes esophagitis on the basis of the clinical and radiographic findings without endoscopic or serologic confirmation. These five cases accounted for about 10% of all cases of herpes esophagitis diagnosed with radiography during this period at our institutions. The double-contrast esophagograms from these five patients were reviewed retrospectively to determine the radiographic
Radiology
MD
In Otherwise
Clinical
report
radiographic wise healthy pes esophagitis ing immunologic patients
S. Levine,
Esophagitis
Patients: The
Marc
#{149}
Gastrointestinal
and
findings.
logic records related with
Endoscopic
were also the barium
reviewed studies.
and
medical records mine the clinical and subsequent
were reviewed presentation, patient course.
to detertreatment,
RESULTS Clinical
Findings
The five patients with herpes esophagitis were male subjects aged 15-23 years who had previously been healthy. All had acute onset of odynophagia for 1-3 days before they sought medical attention. Their odynophagia was characterized by severe substernal chest pain during swallowing. All five patients had a flulike syndrome with fever, sore throat, or myalgias for 3-7 days prior to the development of odynophagia. Two patients had associated ulcers on the lips or buccal mucosa at the time of presentation. One patient indicated that his girlfriend had had “sores” on her lips several weeks before his initial examination. All patients denied taking any oral medications known to cause esophagitis.
Radiographic
Findings
In all five patients, double-contrast esophagograms revealed similar findings, with multiple tiny ulcers 2-S mm in
diameter
(Figs
1, 2, 3a).
The
shallow
areas of ulceration appeared as punctate collections or linear streaks of barium on the mucosa that were too numerous to count. The ulcers tended to be clustered in the middle third of the esophagus,
near
the
level
of the
left
main bronchus, but also extended into the distal third of the esophagus. The ulcers tended to have a linear alignment along the long axis of the esophagus. None of the patients had evidence of a hiatal hernia or spontaneous gastroesophageal reflux at fluoroscopy.
patho-
and corFinally,
Abbreviation: ciency
AIDS
=
acquired
immunodefi-
syndrome.
859
Endoscopic
and
Pathologic
Findings Three patients underwent endoscopy within several days of the radiobogic examination. In all three patients, endoscopic
findings
of
multiple
in
the
confirmed
the
ulcers,
predominantly
tiny
middle
third
of
the
3b). revealed
In one patient, multiple small
spersed
with
(Fig
tients
had
the
presence
esophagus
endoscopy vesicles
ulcers.
All
intranuclear
also inter-
three
pa-
inclusions
on
endoscopic brushings or biopsy samples and/or findings positive for the herpes simplex virus on viral cultures. The two other patients did not undergo endoscopy.
However,
tients
had
pes and
one
of these
elevated
two
serum
pa-
titers
for
her-
simplex antibodies during the convalescent stages, a finding
indicated
herpetic
patient
had
findings
infection.
The
characteristic
and
the
acute that other
radiographic
associated
clinical
pro-
drome; hence, on the basis of previous experience with this condition, he was treated for herpes esophagitis without endoscopic
or
Treatment
and
Four
patients
treatment
with
antacids.
All
clinical
serologic
confirmation.
Patient received viscous
four
lidocaine
received day)
gradual
with
complete
10-12
The
patient,
other
acycbovir
(375
intravenously clinical
hours of the
and had treatment
symptoms
days
mg,
for
striking
and
experienced
of symptoms
presentation.
1.
after
who
three
times
10 days,
had
within
24
response
a
resolved, underwent
study
or endoscopy.
none
of
follow-up
the
1, 2.
(1) Double-contrast
has
pa-
barium
been
well
wise
healthy,
jects
who
documented
are
simplex
The
DISCUSSION
in
virus
type
exposed
virus
core
virus that is found in the salivary glands and secreted in the saliva in about 2% of healthy adults without
or
symptoms
(10).
between infected
subjects may develop
matitis
or
who tern,
virus
who
are herpes
phanyngitis
(1).
have a compromised however, exposure
may
lead
to
patients
herpes malignancy;
treatment
illness; roids,
or
cently,
esophagitis
with
chemotherapy; acquired
esophagitis
860
of
are
#{149} Radiology
gia of
debilitating
ste-
or,
resyn-
of these
the
may
be
otherwise
patient
as an
ways
occurs
ness,
and
after
presentation
these
symptoms
patients
conservatively
with
immunocompromised,
herpes
(viscous
patient
with
herpes
it
acids.
Occasionally,
my-
by
the
to seek
medical
the
odynopha-
herpes
esophagitis
subjects
almost
acute,
atin al-
self-limited As can
topical
3-14
illdays
a result, be
anesthetics and
however,
patients
ant-
severe
odynophagia
without
endoscopy.
is performed, esophagitis
the can
also
If endos-
diagnosis be
of
her-
confirmed
samples.
Although the radiographic findings have been described only anecdotally in the radiology literature (9), our experience indicates that otherwise healthy patients with herpes esophagitis have remarkably similar findings on doublecontrast esophagograms. All of our patients had innumerable punctate or binear areas of ulceration, predominantly located in the midesophagus near the level of the left main bronchus (Figs 1-3).
treated
analgesics,
particularly
with positive viral cultures, direct immunofluorescent staining for the herpes simplex antigen, or demonstration of intranuclear inclusions on brushings or biopsy
which
(1-5). with
lidocaine),
a
(1,2,5-
resolve
usually
have
infection,
Although severe,
lesions
conditions is followed
healthy
pes
lasts 3-10 days by fever, sore
odynophagia,
(1-8).
copy
(2,5,6,8). patients
respiratory
all
prompts
are
these
that
of acute
tention
because
most
healthy
require antiviral drugs such as acyto accelerate healing of the herlesions and alleviate symptoms. titers for herpes simplex virus 1 can be obtained during the acute convalescent stages to confirm the
diagnosis
of esophageal
of
prodrome
onset
all
immunodeficiency
drome (AIDS) (11-14). Although most patients
7). This
herpetic
development
upper or
male
They exposure
mucosa
is characterized
algias,
radiation,
the
prodrome
throat,
almost
immunosuppressed
underlying
and
patients
infection
As a result,
with
clinically
to the
with
most
flulike
immune systo the virus
opportunistic
esophagus.
to
are
(2-7).
of recent
or buccal
symptoms,
(1-8).
usually years
a history
lips
develop
is characteristic
15-30
partners
the
Prior
with
exposed gingivostoIn
have
may cbovir petic Serum type and
associated
pharyngitis
who
aged
to sexual on
is transmitted
patients by direct contact oral secretions. Otherwise
healthy virus
the
The
otherwise
with
herpes
without
presentation patients,
often
the
occasionally or
clinical these
other-
sub-
to
may with
subjects
1 is a DNA
that
immunocompetent
esophagitis
simplex
from
esophagitis, manifested by innumerable punctate and linear areas of ulceration in the midesophagus near the level of the left main bronchus. This patient’s case was reported previously by one of the authors (M.S.L.) (9). (2) Double-contrast esophagogram from another immunocompetent patient with herpes esophagitis, manifested by multiple tiny ulcers with linear arrangement in the midesophagus. Note that radiographic findings are remarkably similar to those in 1.
gingivostomatitis
Herpes
esophagogram
a
no symptoms by the end period. Because their
tients
2.
Figures
conservative
improvement,
resolution
Course
Herpes
esophagitis
in
immuno-
compromised patients is also characterized by ulceration, but such patients tend to have discrete, more widely separated ulcers that are larger and less
March
1992
esophagitis by means of the clinical history and presentation. In summary, herpes esophagitis may occasionally occur in otherwise healthy patients
as
an
acute,
self-limited
illness
manifested by multiple tiny ulcers that are predominantly located in the midesophagus near the level of the left main bronchus. If the characteristic dinical prodrome is present in patients with typical findings on double-contrast esophagograms, these individuals can undergo conservative treatment without need for endoscopic intervenlion. U
References 1.
Depew WT, Prentice RS, Beck IT, Blakeman LR. Herpes simplex ulcerative esophagitis in a healthy subject. Am J Gastroenterol 1977; 68:381-385. Owensb’ LC, Stammer JL. Esophagitis assoriated with herpes simplex infection in an immunocompetent host. Gastroenterology 1978; 74:1305-1306. Springer DJ, DaCosta LR, Beck IT. A syndrome of acute self-limiting ulcerative esophagitis in young adults probably due to herpes simplex virus.Dig Dis Sci 1979; 24:535-539. Solammadevi SV, Patwardhan R. Herpes esophagitis. Am J Gastroenterol 1982; 77:48-50. Deshmukh M, Shah R, McCallum RW. Experience with herpes esophagus in otherwise healthy patients. Am J Gastroenterol 1984; 79:173-176. DiPalma JA, Brady CE. Herpes simplex esophagitis in a nonimmunocompromised host with gastroesophageal reflux. Gastrointest Endosc 1984; 30:24-25. Desigan G, Schneider RP. Herpes simplex esophagitis in healthy adults. South Med 1985; 78:1135-1137. Ginaldi 5, Burgert W, Paulk HT. Herpes esophagitis in immunocompetent patients. Am Fam Physician 1987; 36:160-164. DeGaeta L, Levine MS. Guglielmi GE, Raffensperger EC, Laufer I. Herpes esophagitis in an otherwise healthy patient. AiR 1985; 144:1205-1206. Douglas RG, Couch RB. A prospective study of chronic herpes simplex virus infection and recurrent herpes libialis in humans. J Immunol 1970; 104:289-295. Berg JW. Esophageal herpes: a complication of cancer therapy. Cancer 1955; 8:731-740. Rosen P, Hajdu SI. Visceral herpes virus inlections in patients with cancer. Am J Clin Pathol 1971; 56:459-465. Nash G, Ross JS. Herpetic esophagitis: a common cause of esophageal ulceration. Hum Pathol 1974; 5:339-345. Levine MS, Woldenberg R, HerlinFer H, Laufer I. Opportunistic esophagitis in AIDS: radiographic diagnosis. Radiology 1987; 165: 815-820. Levine MS, Laufer I, Kressel HY, Friedman HM. Herpes esophagitis. AJR 1981; 136:863-
JM, DaCosta
2.
3.
4. 5.
6.
7. 4. Double-contrast esophagogram from an immunocompromised patient with herpes esophagitis, manifested by discrete
8.
ulcers seen en face (black arrows) and file (white arrow) in the midesophagus. that ulcers are larger and less numerous
in proNote and
9.
are more
in im-
10.
widely
munocompetent
separated
than
patients
with
those this
disease. II
Figure
3.
Radiographic
and
endoscopic
cor-
relation in another immunocompetent patient with herpes esophagitis. (a) Doublecontrast esophagogram shows multiple punctate ulcers in the midesophagus. Although findings are more subtle in this case, note the similarity to Figures 1 and 2. (b) Endoscopic photograph shows cluster of tiny ulcers (arrows) in midesophagus.
numerous (Fig 4) (14-17). of the ulcers in otherwise jects
with
herpes
The small size healthy sub-
esophagitis
may
be
related to an intact immune system that contains the herpetic infection and prevents the ulcers from enlarging. In any case, pes by
our
experience
esophagitis
suggests tends
different
radiographic
immunocompromised competent patients. Other conditions ated
Volume
with
superficial
182
#{149} Number
that
to be
findings
and
ulceration
3
in
immunoalso
may
her-
manifested
be associin
the
esophagus. Oral medications such as tetracycline and doxycycline may cause a focal contact esophagitis manifested by multiple shallow ulcers in the midesophagus that are indistinguishabbe from those of herpes esophagitis
(18,19).
However,
a temporal
Radiation
esophagitis,
ulceration,
ally
can
but
be differentiated
these
conditions
from
13. 14.
15. 16. 17.
18.
19.
20.
caustic
esophagitis, and, rarely, esophageal involvement by Crohn disease or Beh#{231}et disease may be associated with superficial
12.
relation-
ship between ingestion of the offending medication and the onset of esophagitis should suggest the correct diagnosis. Reflux esophagitis is a more common cause of ulceration but tends to affect the distal esophagus and is usually associated with a hiatal hernia or gastroesophageal reflux. Recently, cytomegalovirus and human immunodeficiency virus have been identified as other causes of ulceration, but these infections occur primarily in patients with AIDS and are often manifested by giant, relatively flat ulcers in the esophagus
(14,20,21).
.
21.
Shortsleeve MJ, Gauvin GP, Gardner RC, Greenberg MS. Herpetic esophagitis. Radiology 1981; 141:611-617. Levine MS. Loevner LA, Saul SH, Rubesin SE, Herlinger H, Laufer I. Herpes esophagitis: sensitivity of double-contrast esophagography. AIR 1988; 151:57-62. Creteur V. Laufer I, Kressel HY, et al. Druginduced esophagitis detected by double-cona8st radiography. Radiology 1983; 147:365-. Bova JG, Dutton NE, Goldstein HM, Hoberman U. Medication-induced esophagitis: diagnosis by double-contrast esophagography. AJR 1987; 148:731-732. Balthazar EJ, Megibow AJ, Hulnick D, Cho KC, Berenbaum E. Cytomegalovirus esophagitis in AIDS: radiographic features in 16 patients. AJR 1987; 149:19-923. Levine MS. Loercher C, Katzka DA, Herlinger H, Rubesin SE, Laufer I. Giant, human immunodeficiency virus-related ulcers in the esophagus. Radiology 1991; 180:323-326.
usu-
herpes
Radiology
#{149} 861
