Magdalini Pape, corresponding author 1 Kalliopi Mandraveli,1 Ioannis Sidiropoulos, 2 Dimitrios Koliouskas, 2 Stella Alexiou-Daniel, 1 and Filanthi Frantzidou 1
Epstein-Barr virus esophagitis in an immunocompetent host is a rare entity. It represents either primary infection or reactivation and is usually characterized by acute onset and extensive ulcerative involvement of the upper and middle third of the esophagus.
A 27-year-old woman with no past medical history was admitted to the emergency department of our hospital with a 7-day history of dysphagia, especially for solid food, and odynophagia. She had no previous history of upper gastrointestinal complaints or any systemic symptoms. Her physical examination was normal as was an abdominal computed tomography (CT) scan. Routine admission laboratory studies were normal and serological tests (ELISA AXSYM Abbott) for anti-cytomegalovirus, anti-Epstein-Barr virus, anti-herpes simplex virus and anti-varicella zoster virus IgG/IgM antibodies excluded primary infection or reactivation. The serology results for EBV were: IgG (+) 125 IU/ml, IgM (−).
The patient underwent esophagoscopy, using an Olympus endoscope and multiple, well circumscribed ulcerations were identified in the upper and middle section of the esophagus. The ulcers were characterized as either shallow or of intermediate depth. A few deep ulcers were also seen. Viral infection was taken into consideration on the basis of the gastrointestinal symptoms and in the absence of any other demonstrable causes such as drug-induced esophagitis. Biopsy specimens were obtained from the identified ulcers and submitted for histopathologic evaluation. Tissue sections were also stained with hematoxylin and eosin. Microscopically, all specimens showed non-specific features of active esophagitis, including ulceration, neutrophilic and eosinophilic inflammation, and a basal cell hyperplasia. No viral inclusions, hyperchromaticity, or atypical mitoses were observed. Using real-time polymerase chain reaction (PCR) (artus LC PCR, QIAGEN), biopsy and blood specimens were tested for the most and less frequently identified esophageal pathogens (candida, CMV, HSV, EBV). No candida, CMV, HSV or EBV DNA was detected in blood samples. EBV DNA was detected only in tissue samples (1.6 × 103 copies/ml). Therefore, the patient was started on treatment with acyclovir at an oral dosage of 800 mg, five times daily for 5 days, with good resolution of the symptomatology. Follow-up endoscopic examination showed a clear improvement. PCR on biopsy materials was once more performed, but no EBV genome could be detected. Blood samples were also obtained, but no serological evidence of infection was reported. The patient has subsequently remained symptom-free.
Herpes virus esophagitis is a well-known infectious complication in patients with impaired immune system, and has also been described as a self-limiting illness in immunocompetent patients. The herpes viruses so far related to esophagitis are CMV and HSV. Although a few reports have suggested the role of EBV in esophagitis, we believe that EBV infection may activate immune-mediated mechanisms eventually leading to tissue damage. This case report stresses the role of EBV infection in the pathogenesis of esophagitis, a rare condition in the immunocompetent host. In this setting, active infection may represent a primary infection or reactivation.
Histopathological examination alone may lead to incorrect diagnosis, while PCR techniques optimize the diagnostic sensitivity, establish a firm diagnosis and lead to an appropriate therapy.
EBV infection should be considered in all symptomatic patients, immunocompetent or not, in whom esophageal ulceration is identified endoscopically and who are not being treated with immunosuppressants and/or corticosteroids. The PCR technique clearly establishes the diagnosis, leading to an appropriate treatment.
Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
PM is the primary contributing author. SI is a pathological specialist and was the medical internist responsible for the patient. All authors read and approved the final manuscript.
There is no funding source since this brief case report had no cost. Mandraveli Kalliopi, the Associate Director of the Infectious Disease Department of AHEPA Hospital, Stella Alexiou-Daniel, Professor of Medical Microbiology and Koliouskas Dimitrios, Associate Director of the First Propedeutic Medical Department are all thanked for their help in reading the final manuscript.
- Baehr PH, McDonald GB. Esophageal infections: risk factors, presentation, diagnosis, and treatment. Gastroenterology. 1994;106:509–532. [PubMed]
- Conolly GM, Hawkins D, Harcourt-Webster JN, Parsons PA, Husain OA, Gazzard BG. Esophageal symptoms, their causes, treatment, and prognosis in patients with the acquired immunodeficiency syndrome. Gut. 1989;30:1033–1039. doi: 10.1136/gut.30.8.1033. [PMC free article] [PubMed] [Cross Ref]
- Claudio PO, Patrizia PA. Gastrointestinal complications in renal transplant recipients. Transplant Int. 2005;18:643–650. doi: 10.1111/j.1432-2277.2005.00134.x. [PubMed] [Cross Ref]
- Wilcox CM, David A, Schwartz W, Scott C. Esophageal ulceration in human immunodeficiency virus infection: causes, response to therapy, and long-term outcome. Ann Intern Med. 1995;123:143–149. [PubMed]
- Bodak DA. Gastrointestinal infections caused by Cytomegalovirus. Curr Infect Dis Rep. 2003;5:101–107. doi: 10.1007/s11908-003-0044-4. [PubMed] [Cross Ref]
- Ramanathan J, Rammouni M, Baran J Jr, Khatib R. Herpes simplex virus esophagitis in the immunocompetent host: an overview. Am J Gastroenterol. 2000;95:2171–2176. doi: 10.1111/j.1572-0241.2000.02299.x. [PubMed] [Cross Ref]
- Bertalot G, Villanci V, Gramegna M, Orvieto E, Negrini R, Saleri A, Terraroli C, Ravelli P, Cestari R, Viale G. Evidence of Epstein-Barr virus infection in ulcerative colitis. Dig Liver Dis. 2001;33:551–558. doi: 10.1016/S1590-8658(01)80106-7. [PubMed] [Cross Ref]
- Wakefield AJ, Fox JD, Sawyerr AM, Taylor JE, Sweenie CH, Smith M, Emery VC, Hudson M, Tedder RS, Pounder RE. Detection of herpesvirus DNA in the large intestine of patients with ulcerative colitis and Crohn’s disease using the nested polymerase chain reaction. J Med Virol. 1992;38:183–190. doi: 10.1002/jmv.1890380306. [PubMed] [Cross Ref]