A 22-year-old, white, single female medical student reported pain when swallowing. The pain manifested four days prior to presentation and began with a burning epigastric pain and intense heartburn. The patient was self-medicated with omeprazole and domperidone without success. After approximately 12 hours, there was a change in the pattern of pain, which was constrictive and intermittent and was located in the sternal region.
The patient developed asthenia, malaise, appetite loss, and a daily fever of up to 38.5 C during the afternoon/early evening. She reported a weight loss of 5 kg over one week with associated nausea and odynophagia for solids, pastes, and liquids. She initially experienced pain only in the distal esophagus, which later expanded to the full extension of the esophagus.
A physical examination revealed mild hyperemia in the oropharynx, good general condition and mucous with normal coloration. The patient was hydrated, afebrile, acyanotic, and anicteric. Her respiratory system, cardiovascular system, and abdomen were unchanged. Additionally, she had no cervical, axillary, or inguinal lymphadenopathy.
The tests performed on the patient are listed in the board table, and the results are provided in Table 1.
The following observations were made during upper digestive endoscopy (Figure 1): numerous injuries on the esophageal surface that were yellow-whitish in color, pleomorphic and isolated in small circular plaques with central erosions and even depression with hyperemia at baseline; these injuries were more prominent in the distal third of the esophagus, indicating infectious esophagitis.
During the anatomic pathological examination of the esophagus, the esophageal mucosa showed ulceration with the presence of multinucleated cells with overlapping nuclei and ground-glass aspect, which is consistent with herpetic infection (Figure 2).
An immunohistochemical study of the patient's esophagus revealed that the patient was positive for herpes virus type 1 (Figure 3). The assay utilized was a polyclonal rabbit antiherpes simplex virus type 1 assay (Dako, Albertslund, Denmark).
The patient was treated with oral acyclovir (800 mg) 5 times a day for 7 days. Early improvement was noted on the third day, and complete resolution of symptoms was achieved in 1 week.