Case Presentation: A 44 yo female with a history of ESRD, hypertension, and diabetes mellitus presented to the ED with nausea. She was admitted to the ICU with concerns for diabetic ketoacidosis and hyperkalemia with a glucose 505, potassium 7.2, and anion gap 27. She was tachypneic, and initial workup revealed leukocytosis 15.2. After 2 days in the ICU on DKA protocol her anion gap stabilized and she was transferred to the medicine floor. She then developed nausea, vomiting, and odynophagia with oral intake. She was afebrile with stable vital signs, no thrush was appreciated on exam, but there was persistent leukocytosis. Gastroenterology service was consulted and recommended an EGD which showed findings of Candida esophagitis (CE). She was discharged home on oral fluconazole for 14-21 days with biopsy results pending. Pathology report showed viral inclusions consistent with Herpes Simplex esophagitis (HSE). Plan was set to start acyclovir if symptoms persisted.
Discussion: Here we present a patient with no history of recurrent infections or other findings suggestive of immunodeficiency, who was diagnosed with combined HSE and CE. HSE is an opportunistic infection and is usually found in patients with malignancy, AIDS, or in patients on immunosuppressive therapy (1). Few reports have described immunocompetent individuals with HSE or CE (2,3). Reports of combined CE and HSE in immunocompetent hosts are also rare (4). There was no corticosteroid use or risk factors for HIV infection. Reports in adults with combined infections may be due to injury to the esophageal epithelium and disruption of the mucosal barrier by HSV, creating a supportive environment for Candida species (5). HSE can occur from reactivation of underlying infection and infection spread from oral cavity to esophagus. Patients usually present with odynophagia, dysphagia, fever, severe chest or retrosternal pain, and gastrointestinal bleeding (7) concurrent with symptoms or history herpes labialis. Endoscopy with biopsies for culture and histologic studies remains the investigation of choice. Diagnosis can be made by the appearance of classical histologic appearance of multinucleated giant cells with eosinophilic intranuclear inclusions referred to as Cowdry type A bodies (9). Candidal esophagitis is diagnosed with the appearance of Candida spp. are seen along with squamous cells and invading hyphae on smears (8).
Conclusions: Combined HSE and CE is a sporadic occurrence, and occurs even more rarely in patients who are non-immunocompromised. This case highlights the importance of endoscopy with biopsy to investigate possible multifactorial causes of esophagitis, even immunocompetent patients. In severe cases of esophagitis with two pathogens, treatment for both organisms is recommended.