Viral Esophagitis - Causes, Symptoms, Diagnosis, and Treatment

Introduction

Any inflammation, irritation, or swelling of the esophagus caused by viruses is termed viral esophagitis. This usually occurs in immunocompromised patients. Infectious esophagitis is rare in a healthy individual, as the immune system immediately destroys any foreign body detected.

What Is Esophagitis?

Esophagitis is the inflammation of the tissues lining the esophagus. If left untreated, they can be uncomfortable and cause problems in swallowing, ulcers, and scars in the esophagus. There can be many causes for esophagitis, and when the cause is a virus, it is called viral esophagitis.

What Is Viral Esophagitis?

Viral esophagitis is any inflammation, irritation, or swelling of the esophagus caused by viruses. This usually occurs in immunocompromised patients (people whose immunity is weak). The herpes simplex virus and the cytomegalovirus usually cause it. The human papillomavirus also causes esophagitis at times. It might take one to three weeks to recover.

What Causes Viral Esophagitis?

Viral esophagitis is usually found in patients with weak immunity. The reasons behind weak immunity can be:

• HIV/AIDS.

• Chemotherapy.

• Diabetes.

• Leukemia.

• Medicines that suppress the immune system, like those given after an organ transplant.

• Long-term use of antibiotics.

• Alcohol abuse.

• Age- As people get older, their immune system becomes weaker.

• Other conditions can weaken the immune system.

How Is Viral Esophagitis Different From Reflux Esophagitis?

Both viral and reflux esophagitis have the same clinical presentations. However, the diagnosis can be confirmed by the patient’s history. For example, if the patient has a history of an organ transplant or gives any clue that they are HIV positive, are undergoing chemotherapy, are on steroids for some reason, etc., they can be classified as having viral esophagitis since they are immunocompromised.

What Are the Symptoms of Viral Esophagitis?

• Dysphagia (difficulty in swallowing).

• Odynophagia (pain while swallowing).

• Throat issues.

• Retrosternal chest pain (pain inside the chest, particularly behind the breast bone).

• Inflammation.

• Fever.

• Ulcers around the mouth and oropharynx.

• Joint-pain.

• Malaise(general feeling of being unwell).

• Fatigue.

• Heartburn.

• Substernal burning pain(a burning sensation that spreads from the tip of the breast bone)

How Is Viral Esophagitis Transmitted?

Viral esophagitis is usually transmitted through direct contact with the contaminated substance. Direct contact can be mouth-to-mouth through contact with the infected person’s saliva. It can also be transmitted through unprotected sex, though this is rare. Herpes simplex virus type 2 can be transmitted through oral sex.

How Can Viral Esophagitis Be Prevented?

• Thorough and frequent washing of hands with soap and warm water, avoiding or limiting direct contact with an infected person, engaging in safe sexual activity, etc., are some ways to prevent the transmission of the virus.

• The initial symptoms of a viral infection include throat irritation and fever. It is always better to prevent the infection from spreading. The key to preventing the infection from spreading is detecting the symptoms in the initial stage and preventing it.

How Is Viral Esophagitis Diagnosed?

1. A thorough case history is taken to understand the source of infection, symptoms presented, duration of the presenting symptoms, etc.

2. Physical examination includes checking mouth and throat for ulcers and other symptoms.

3. Blood tests can be advised to determine the causative pathogen and rule out other conditions.

4. An endoscopy can be done to check the esophagus for signs of inflammation and ulcers. Ulcers less than 2cm can be observed in the distal esophagus. In herpes-simplex esophagitis, the ulcers will be well-circumscribed and have a volcano-like appearance. Diffuse erosive esophagitis(a type of esophagitis where the lining of the esophagus is destroyed) can be observed in herpes-simplex esophagitis. In cytomegalovirus esophagitis, the ulcers will be linear and deep.

5. A biopsy can be done, if necessary, to confirm the diagnosis. It can be done along with the endoscopy as well. Multinucleated giant cells with ground glass nuclei and eosinophilic inclusions (a characteristic feature of viral infections) are found on histologic evaluation in Herpes-simplex esophagitis. In a cytomegalovirus infection, tissue destruction and intranuclear inclusion bodies (seen in viral infections) can be seen histologically.

How Is Viral Esophagitis Treated?

• The treatment for viral esophagitis depends on the patient’s immune system.

• Viral esophagitis usually gets resolved in people with a normal immune system (though the chance of people with a normal immune system getting viral esophagitis is meager).

• A short course of oral acyclovir 400 mg, three times daily for one to two weeks, can be given for faster recovery if required.

• Patients with a weakened immune system need to be treated longer. Oral acyclovir 400mg can be given five times daily for two to three weeks.

• Alternatively, valacyclovir 1gm thrice a day for two to three days can be given.

• Patients with severe difficulty swallowing the oral medication might require hospitalization for parenteral delivery of the drug. They can be switched to the oral drug as they get better at swallowing the oral form of the drug.

What Is Cytomegalovirus-Induced Esophagitis?

• Cytomegalovirus (CMV)-induced esophagitis is seen in those who have had an organ transplant, those who undergo long-term dialysis, those who are HIV-infected, or those on long-term steroid therapy.

• No literature has come across CMV-induced esophagitis in a healthy individual.

• The average time for a patient undergoing an organ transplant to develop CMV esophagitis is about six months.

• Induction therapy using ganciclovir 5 mg/kg for three to six weeks is given in CMV esophagitis.

• A maintenance therapy using oral valganciclovir 900 mg twice daily is done in patients who have relapsed.

What Are the Complications of Viral Esophagitis?

Complications are very rare, though they can be seen in severe immunodeficiency. They may include:

• Spread of the infection to other parts of the body.

• Scar formation in the esophagus causes esophageal stricture(narrowing the esophagus).

• Bleeding from the ulcers in the esophagus.

• Esophageal fistula or perforation(a hole in the esophagus).

Conclusion

Esophagitis is the inflammation of the tissues of the esophagus, and when a virus causes it, it is called viral esophagitis. The condition is commonly seen in immunocompromised patients. Treatment includes taking antiviral drugs and avoiding anything that might trigger the condition. Recovery depends on the patient’s immune system and the response to the medications used.