Herpes Simplex Virus Esophagitis in the Setting of Acute Use of Corticosteroids for COPD Exacerbation in an Immunocompetent Middle-Aged Woman

Herpes simplex (HSV) esophagitis is usually identified in patients with significant immunosuppressive conditions such as AIDS. Short course of immunosuppressive therapy is an uncommon risk factor for this condition. We present a case of acute gastrointestinal bleeding secondary to HSV type 1-induced esophageal ulcers. A 63-year-old woman developed acute hypoxic hypercapnic respiratory failure. Past medical history was significant for COPD for which the patient was taking short-acting bronchodilator inhalers. The patient was intubated and started on mechanical ventilation. Intravenous Solu-Medrol 40 mg Q6 was started. Hospital course was complicated by sepsis of unknown source. Empiric broad-spectrum antibiotic therapy was started. On the 11th hospital day, the patient experienced multiple episodes of coffee ground emesis. There was abdominal tenderness on physical examination. Significant laboratory results were lipase 1,911 U/L and lymphopenia (ALC = 300/mm(3)). Endoscopy revealed severe erosive esophagitis and multiple punched-out ulcerations of the esophagus. Empiric treatment with valacyclovir 500 mg OD was started. The patient required PEG tube insertion for dysphagia. Complete resolution of esophagitis was noted then. Immunohistochemical staining for HSV was strongly positive in the cells with inclusions. Short course of intravenous corticosteroids is an uncommon cause of HSV-1 esophagitis. Corticosteroid-induced lymphopenia impedes underlying cellular immunity, which might explain the reactivation of latent herpes and esophageal ulcer formation. Given the rarity of the disease, evidence of treatment is available from case reports only. We found complete resolution of esophageal ulcers after the patient received valacyclovir therapy for 10 days.