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.