Herpes simplex esophagitis

Last author update: 1 October 2012
Last staff update: 16 May 2022

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PubMed Search: Herpes simplex[TI] esophagitis[TI]

Elliot Weisenberg, M.D.
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Cite this page: Weisenberg E. Herpes simplex esophagitis. website. Accessed August 13th, 2022.
Definition / general
  • #2 most common cause of infectious esophagitis after Candida
  • Self limited in healthy patients; may cause esophageal perforation or disseminate in immunocompromised patients
  • May have secondary bacterial or fungal infections
  • Must rule out HSV infection as cause of esophageal ulcers, particularly from immunocompromised patients
  • Histology, culture, PCR
Case reports
Gross description
  • Shallow vesicles and ulcers; may coalesce into extensive areas of erosion
Gross images

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Punched out ulcers

Microscopic (histologic) description
  • Ulcers contain necrotic debris and exudate with neutrophils
  • Viral inclusions are present in multinucleated squamous cells at margin of ulcer; inclusions are usually Cowdry type A (dense eosinophilic intranuclear and cytoplasmic) with thickened nuclear membrane and clear halo; also ground glass inclusions that fill the nuclei and nuclear molding; inclusions may be absent in endoscopic biopsy specimens
  • Aggregates of macrophages with convoluted nuclei are adjacent to inflamed epithelium
  • Prominent mononuclear infiltrate (Hum Pathol 1991;22:541)
  • Concurrent infection with CMV may occur; its inclusions are usually found in endothelial and stromal cells
Microscopic (histologic) images

Contributed by Raul S. Gonzalez, M.D., Joseph C. Castillo, M.D., Mario Prieto, M.D., Ph.D., Nilesh Patel, M.D. and Mark R. Wick, M.D.

Focal viral cytopathic effect

Margination, multinucleation, and molding

Ground glass nuclei

Cowdry type A inclusions

38 year old woman with esophagus ulcer; florid herpes esophagitis with diagnostic Cowdry A inclusions and multinucleated cells with nuclear molding and ground glass nuclei

70 year old
man with Candida
and herpes esophagitis

Erosive herpes esophagitis

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Ground glass intranuclear inclusions

Multinucleated giant cells

Positive stains
  • CD68 (large cells with convoluted nuclei)
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