Herpes oesophagitis. II. Electron microscopical findings

[Evaluation and management of infectious esophagitis in immunocompromised patients and immunocompetent individuals]

Among the many causes of the inflammatory process in the esophagus, infectious diseases are becoming increasingly important due to their steady growth. Previously esophageal infections have traditionally been associated with immunodeficiency syndromes, but now in clinical practice, these disorders are becoming increasingly recognized in immunocompetent individuals. Early diagnosis of infectious esophagitis is necessary to develop effective treatment tactics, and, as a result, reduce the risk of complications and adverse outcomes of the disease. This study reviewed the most clinical relevant pathogens of infectious esophagitis, both among patients with immunodeficiency and among healthy individuals. Specific diagnostic, risk factors, clinical presentation and therapeutic features were considered depending on the immune status of patients.

Infectious Esophagitis

Infectious esophagitis can have significant implications in an impaired host. Described most commonly in immunocompromised patients, infectious esophagitis can also occasionally be discovered in immunocompetent individuals in several unique clinical settings. Evaluation of the typical presenting complaints, such as dysphagia or odynophagia, are especially important in immunocompetent patients, and therapy should be directed at the appropriate predisposing condition and resultant infectious agent. In immunocompromised patients, however, clinical experience supports the use of empiric therapy in patients without concomitant systemic complaints. Especially in AIDS patients or those with lymphoma or leukemia, the initial approach to infectious esophagitis complaints (ie, dysphagia or odynophagia) is to begin an empiric trial of oral systemic fluconazole for presumed candidal esophagitis. If the individual remains symptomatic after 3 to 7 days or has any associated systemic complaints or concerning clinical findings (eg, hematemesis), then upper endoscopy with biopsies is indicated. If an etiologic agent other than Candida is defined by histologic, immunohistochemical, or culture methods, then appropriate therapy can be initiated. There are many important and pathologic agents implicated in infectious esophagitis. Thus, directed therapy needs to be administered appropriately and in a timely fashion to avoid poor short-term problems or long-term sequelae.

Herpes oesophagitis. I. Light microscopical and immunohistochemical investigations

The diagnosis of herpes oesophagitis was established from routinely processed biopsy specimens and cytological brush preparations of six patients by immunoperoxidase staining of herpes simplex virus (HSV)-antigen. Macroscopically small round punched-out ulcers are the most frequent and characteristic feature of herpes oesophagitis, whether occurring in patients with serious debilitating illnesses, under immunosuppression, or without evidence of any significant disease. Light microscopically the herpetic changes of squamous epithelium consist of ballooning degeneration, ground glass nuclei with margination of chromatin, eosinophilic inclusions and multinuclear giant cells. A specific positive reaction with anti-HSV is found only at the borders of the oesophageal ulcers. The immunostaining intensity of nuclei and cytoplasm varies from cell to cell according to the mode of HSV replication in productive infected cells. The latency of HSV in the vagus ganglion and centrifugal neural spread are discussed.