Discussion:
The esophagus is frequently a target for infections in immunocompromised individuals, particularly transplant recipients, those receiving chemotherapy or steroids, and organ transplant recipients. However, concurrent infections by multiple viruses are rare (2, 3).
Various microorganisms, most notably Candida, HSV, and CMV, can cause infectious esophagitis. HSV-related esophagitis primarily affects immunocompromised hosts, although it can also occur less frequently in immunocompetent individuals (4). Endoscopically, characteristic findings include erosions and distinct ulcers with yellow borders, predominantly in the distal esophagus (5, 6). Microscopically, these ulcers exhibit multinucleated squamous cells at their edges, displaying nuclear molding and a ground-glass appearance with chromatin margination and eosinophilic intranuclear inclusions (Cowdry A-type)(6).
CMV esophagitis also tends to occur in immunocompromised patients such as those with HIV, long-term steroid users, and organ transplant recipients. The ulcers associated with CMV are larger and differ from those caused by HSV, being linear, longitudinal, deep, and typically located in the distal esophagus (5, 6). Histologically, these ulcers demonstrate viral cytopathic effects at the ulcer base in infected endothelial, stromal, or glandular epithelial cells characterized by cellular and nuclear enlargement and large intranuclear inclusions separated from the nuclear membrane by a halo. Cytoplasmic inclusions may also be observed (6).
Bonacini et al. and Wilcox et al. investigated the causes of esophageal infections in patients with HIV, identifying CMV as a frequent cause, followed by idiopathic ulceration and infections by HSV, with coinfections of CMV and HSV being particularly rare (3, 5). Further investigations in transplant recipients by McDonald et al. demonstrated that a significant proportion develop infectious esophagitis, primarily caused by HSV, CMV, and Candida, with a notable incidence of coinfection between CMV and HSV (7, 8).
Our case highlights the clinical complexity and diagnostic challenge of esophagitis due to concurrent CMV and HSV-1 infections in a post-liver transplant patient. While single CMV and HSV infections are relatively common in post-transplant patients due to their immunocompromised status, simultaneous infection of the esophagus with both viruses is notably rare but critical to recognize due to potentially severe complications(3). While the number of reported cases remains scarce, a recent series by Bannoura et al. shed light on the coinfection of the esophagus with CMV and HSV in immunocompromised patients (9). However, none of these cases exhibited such a severe and distinctive gross endoscopic presentation as observed in our patient’s case.