An 82-year-old female underwent upper endoscopy prompted by unspecific abdominal pain and iron deficiency anaemia. The procedure disclosed an ulcer in the distal stomach that had developed against a background of reactive gastropathy. The oesophagus was diffusely inflamed, displaying whitish plaques that could not be scrapped (Panels A-B). Cytological brushes and biopsies were taken.
Cytology disclosed groups of squamous cells with enlarged ground-glass nuclei with homogenous chromatin pattern and multinucleation (Panels C-D). Upon histology, we observed multiple fragments of squamous epithelium with degenerating features admixed with inflammatory detritus. The nuclei of the squamous cells displayed ground-glass morphology as documented in the cytological material (Panels E-F). Immunostaining for Herpes simplex virus (HSV) I and II was positive (Panels G-H).
HSV accounts for 10% of all infectious oesophagitides and is considered the most common viral cause, mostly due to HSV-I. Primarily, it occurs in immunosuppressed patients (prior chemotherapy, solid and bone marrow transplantation recipients, and HIV infection), but may also encounter in healthy immunocompetent individuals with usually mild symptoms, as a self-limited infection.
Herpetic ulcers are usually superficial from a few microns to few cm, preferably located in the middle and distal oesophagus. Grossly, HSV esophagitis lesions are grouped into three types: (i) small, punched out lesions with raised margins, coated with yellowish exudate, (ii) small, punched out lesions without raised margins or exudate and (iii) multiples ulcers, with a map-like confluent appearance over the entire oesophagus, often surrounded by normal-appearing mucosa.
Histologically, the virus infects oesophageal squamous epithelium, typically at the superficial lateral margin of ulcers and erosions. The morphological diagnostic criteria include: (i) dense intranuclear eosinophilic to amphophilic round inclusion bodies with a clear halo separated from the nuclear membrane (Cowdry A inclusions), (ii) ground-glass nuclei with homogenous chromatin pattern, (iii) nuclear molding, (iv) multinucleated syncytia giant cells and (v) detached ballooning degeneration of infected cells. Immunohistochemistry studies is helpful in equivocal cases.
