HSV esophagitis {HE}

Ahmed Mohamed BadheebProf Of Oncology & Internal Medicine

Management

• Treatment includes the following components:• Hemodynamic stabilization (eg, in cases of bleeding or perforation)• Pain management – Because chest pain of esophageal origin cannot

be accurately differentiated from chest pain associated with CAD, prehospital protocols for the latter should be followed

• Specific therapy, depending on the cause of the esophagitis and any complications

• Treatment of reflux esophagitis may include the following:• Histamine-2 receptor antagonists (H2RAs)• Proton pump inhibitors (PPIs)• Cisapride (a gastroprokinetic agent)• Sucralfate (a coating agent)

Management

• Although HE may resolve spontaneously, in immunocompetent but also in immunodepressed patients , antiviral treatment is always indicated to prevent the diffusion of the infection, and/or to limit the risk of dehydration, malnutrition and local sequelae.

The treatment of choice for HE• Acyclovir remains the treatment of choice for HE, although

very few controlled studies are available.

• Oral administration seems as efficient as the intravenous route, but is frequently impossible because of dysphagia, odynophagia and vomiting.

• 800 mg PO q4hr while awake (5 times daily) for 7-10 days

• Intravenous administration (15 mg/kg/day or 250 mg/m2/day) is usually rapidly effective in solid organ transplant recipients , AIDS patients or marrow transplant recipients .

Treatment failure

• In immunodepressed patients, treatment failure may be explained by esophageal co-infections or other esophageal disease

Acyclovir-resistant mucocutaneous herpes infections

• Some HE may be due to acyclovir-resistant viral strains , more frequently in patients who have been repeatedly exposed to this drug . Such cases should be treated with foscarnet , which is superior to vidarabine for acyclovir-resistant mucocutaneous herpes infections in AIDS .

Primary prophylactic acyclovir treatment

• Primary prophylactic acyclovir treatment can be considered in high-risk immunodepressed patients, but not in AIDS patients. Indeed, when given 3 days before bone marrow transplantation, it prevented HSV reactivation and reduced the incidence of HSV infections from 50–80% to less than 10% .

Prophylactic acyclovir

• In AIDS, HE recurrences are uncommon and suppressive therapy should not be systematically prescribed. However, in cases of frequent or severe recurrences, a preventive regimen (600–1000 mg in 3–5 divided oral doses per day) may be administered.

HSV esophagitis

• Acyclovir• foscarnet (for acyclovir-resistant cases), or • famciclovir

Management

• Antiviral Agents• Antiviral agents are used to treat herpes

simplex virus (HSV) or cytomegalovirus (CMV) infections. In addition to the drugs listed below, famciclovir (Famvir), a prodrug of the antiviral agent penciclovir, which is not currently recommended for treatment, may replace acyclovir in prophylaxis and treatment.

(Acyclovir Zovirax)

• Acyclovir is a synthetic purine nucleoside analog that stops replication of viral DNA. It is used to treat HSV esophagitis.

Foscarnet (Foscavir)

• Foscarnet is an organic analog of inorganic pyrophosphate that inhibits replication of HSV and CMV. It is used to treat acyclovir-resistant cases.

Ganciclovir (Cytovene)

• Ganciclovir is an acyclic nucleoside analog that inhibits replication of herpes viruses. It is active against CMV and HSV.

Famciclovir (Famvir)

• Famciclovir is goes through biotransformation to active penciclovir. Penciclovir has inhibitory activity against varicella-zoster virus (VZV) and herpes simplex virus types 1 and 2. It may be used for herpes and VZV esophagitis.

CONCLUSION

• HE is common in immunocompromised patients and should be systematically suspected in cases of odynophagia, chest pain, unexplained nausea or upper digestive tract bleeding. Most of the time, HE results from HSV-1 reactivation and the regional extension of an oral or pulmonary infection. Diagnosis is suggested through endoscopy, which usually displays ulcerated esophagitis predominantly in the lower third. The combination of brush cytology, histology and viral cultures allows the best diagnostic sensitivity. Empirical acyclovir treatment also allows a presumptive diagnosis when it is rapidly effective. Finally, HE most often presents as a benign condition when it is diagnosed early and treated.

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