Patient Report Herpes simplex primo-infection in an immunocompetent host with eosinophilic esophagitis Orjena Žaja Franulovic ´, 1 Tatjana Lesar, 1 Nikolina Busic 3 and Goran Tešovic ´ 2 1 Department of Pediatric Gastroenterology and Hepatology, University Hospital Centre ‘Sestre milosrdnice’, 2 School of Medicine, University Hospital for Infectious Diseases, University of Zagreb, Zagreb, and 3 Department of Infectious Diseases, General Hospital Varaždin, Varaždin, Croatia Abstract Eosinophilic esophagitis and herpes simplex esophagitis are separately well-described entities, but their simultaneous occurrence may pose a special challenge to the clinician, especially regarding the optimal therapeutic approach. The following case report describes a patient with a history of cow’s milk and dairy products intolerance, but without an underlying immunologic defect, in whom eosinophilic esophagitis was diagnosed in the course of primary herpes simplex virus 1 (HSV1) infection that clinically presented as herpes labialis and severe esophagitis. The diagnosis was confirmed by a polymerase chain reaction from cytological brush and by immunohistochemical staining that detected the presence of HSV1 DNA in esophageal mucosa, and histologically by persistent eosinophil-predominant inflam- mation, typical of eosinophilic esophagitis. Despite severe clinical presentation, the HSV1 infection was self-limited. After a directed elimination diet was introduced, the clinical course was favorable, without the need for antiviral therapy. Key words eosinophilic, esophagitis, food allergy, hematemesis, herpes simplex. Eosinophilic esophagitis (EoE) is thought to be a result of an allergic response to food antigens or aeroallergens, possibly trig- gered by environmental factors, including microorganisms. 1–3 Herpes simplex esophagitis (HSE) is a rare clinical manifestation of herpes simplex virus 1 (HSV1) primary infection or reactiva- tion, typically occurring in immunocompromised patients, par- ticularly those with cellular immunodeficiencies; however, it is being increasingly recognized in immunocompetent hosts, espe- cially if there is an underlying esophageal lesion present. 4 Although both of the entities are separately well described, if they occur simultaneously, clinicians have to deal with a variety of challenges that often arise in the management of these patients, from answering the question, “What happened first?”, to resolv- ing the dilemma about the need for antiviral therapy in an immu- nocompetent host. In this article we report our experience in treating a patient with a history of cow’s milk and dairy products intolerance, without underlying immunologic defect, in whom EoE was revealed during the HSV1 primary infection which clinically presented as herpes labialis and severe esophagitis. Case Report A 17-year-old girl presented to our emergency department with an acute onset of epigastric pain, heartburn and hematemesis. Her personal history revealed cow’s milk allergy, which manifested as vomiting and abdominal discomfort, but without allergy testing confirmation. She had no history of gastroesophageal reflux, non-steroidal anti-inflammatory drug intake, tobacco or alcohol use, unusual ingestion, self-induced vomiting or having been sexually active. No “cold sores” or episodes of gingivosto- matitis had been previously registered either. On admission, her vital signs were as follows: temperature 37.8°C, blood pressure 110/65 mmHg, pulse rate 80 b.p.m., res- piratory rate 19 breaths per minute, and oxygen saturation 97% on room air. She appeared pale and dehydrated, with febrile blister on her upper lip, complaining of severe retrosternal and epigastric pain. Her oropharynx had no lesions or exudate and there was no skin rash or other lesions. Lungs, cardiac and abdominal examination revealed normal physical findings except epigastric discomfort on palpation. C-reactive protein was slightly elevated (22.9 mg/L), while the erythrocyte sedimentation rate, complete blood count and results of other biochemical tests were all within normal values. Esophagogastroduodenoscopy (EGD; Olympus GIF-Q180 8,8 videoendoscope; Olympus, Tokyo, Japan) was performed the morning after admission. At the proximal part of the esophagus, patchy white plaques were seen tending to merge toward the distal part. Distal to the middle part, longitudinal deep ulcerations Correspondence: Orjena Žaja Franulovic ´, MD PhD, Department of Pediatric Gastroenterology and Hepatology, University Hospital Centre ‘Sestre milosrdnice’, Vinogradska 29, Zagreb, Croatia. Email: orjenazf@yahoo.com Received 18 January 2012; revised 6 September 2012; accepted 26 October 2012. Pediatrics International (2013) 55, e38–e41 doi: 10.1111/ped.12027 © 2013 The Authors Pediatrics International © 2013 Japan Pediatric Society