PROCAARE: CLINICAL SCIENCE--OPPORTUNISTIC INFECTION--ESOPHAGITIS

[Albert Shaw <ashaw@usa.healthnet.org>]

KEYWORDS: OPPORTUNISTIC INFECTIONS/ ESOPHAGITIS/ HERPES SIMPLEX/ RISK 
FACTORS/ THERAPY/ ACYCLOVIR
=====================================================================

Reference: Genereau, T., Lortholary, O., Bouchard, O., Lacassin, F., 
Vinceneux, P., De Truchis, P., Jaccard, A., Meynard, J.-L., Verdon, R., 
Sereni, D., Marche, C., Coulaud, J.-P., Guillevin, L. (1996).  Herpes 
simplex esophagitis in patients with AIDS: report of 34 cases.  Clin. 
Infect. Dis. 22: 926-31.

This retrospective study examined 34 patients with AIDS and esophagitis 
from herpes simplex virus type I (HSV-1).  For 27 patients, HSV-1 
esophagitis was demonstrated either histologically or by positive 
esophageal viral cultures; 7 cases were thought to be probable HSV-1 
esophagitis on the basis of a response to acyclovir.

The median CD4 count of the enrolled subjects was 15/mm3.  Dysphagia or 
odynophagia was reported by 82% of subjects; chest pain was found in 68%, 
and fever in 44%.  Only 38% of patients had concomitant extraesophageal 
HSV-1 infection.  Nine patients were on antiretroviral therapy, and 3 
were taking acyclovir when they joined the study.  Sixteen (47%) had 
potential risk factors for HSV-1 esophagitis, including nasogastric 
intubation or gastroscopy (10 patients, or 29%), corticosteroid use (>0.5 
mg/kg/day for at least 3 days) within 10 days of diagnosis (7 patients, 
or 21%), and cancer chemotherapy within 1 month of diagnosis (5 subjects, 
or 15%).  On endoscopy, lesions were observed in the distal third of the 
esophagus in 17 subjects (50%), the middle third in 4 (12%), and the 
proximal third in one patient; diffuse involvement was reported for 11 
(32%).  

Treatment with acyclovir (15-30 mg/kg/day, either PO or IV [adjusted for 
renal function]) caused a complete response in 24 of the 34 patients, with 
a mean time of  9 days reported for clinical response. The reasons for 
therapeutic failure are not clear, and in particular, acyclovir susceptibility
testing was not reported.   Five patients (15%) subsequently had relapsed 
disease less than 4 months later, though it is unclear if these subjects were 
placed on long term HSV-1 prophylaxis.

Though the retrospective nature of this study and the small numbers of 
patients precluded an assessment of the incidence of herpetic esophagitis 
and the efficacy of diagnostic methods, this is nevertheless the largest 
series to date of AIDS-associated HSV-1 esophagitis.  The results 
emphasize that HSV-1 esophagitis is a late manifestation of AIDS, can 
occur in the absence of mucocutaneous HSV infection, and is usually 
responsive to high-dose acyclovir.