When our map is incomplete: A case of HSV Esophagitis

... In that Empire, the Art of Cartography attained such Perfection that the map of a single Province occupied the entirety of a City, and the map of the Empire, the entirety of a Province. In time, those Unconscionable Maps no longer satisfied, and the Cartographers Guilds struck a Map of the Empire whose size was that of the Empire, and which coincided point for point with it. The following Generations, who were not so fond of the Study of Cartography as their Forebears had been, saw that that vast map was Useless, and not without some Pitilessness was it, that they delivered it up to the Inclemencies of Sun and Winters. In the Deserts of the West, still today, there are Tattered Ruins of that Map, inhabited by Animals and Beggars; in all the Land there is no other Relic of the Disciplines of Geography.
— "On Exactitude in Science", Jorge Luis Borges, A Universal History of Infamy

Today Dr. Chapa presented a perplexing case of a young otherwise healthy male who presented with esophagitis NOS. In time, he was found to have HSV esophagitis without evidence of being immunocompromised.

Dr. Chapa offered a way to think through situations that don't fit one of our classic illness scripts.

  1. Consider that there are 2 things happending that were mistkan for a single phenomenon. (Hickam's dictum states that a patient can have as many diagnoses as they choose vs. Occam's razor states that the simplest explanation is most likely)
  2. You may be dealing with something "very strange". This may be a new phenomenon (remember the emergence of AIDs, etc) OR your knowledge base is incomplete.
  3. Consider that your information is "bad". Remember that no test is perfect and to think about sensitivity, specificity, positive predictive value and negative predictive value as appropriate.

HSV esophagitis in immunocompetent patients is noted in case reports. The American Journal of Gastroenterology commented on this in 2000 where they described 38 cases. Of those cases,

  • Most commonly presents as 3-21d of fevers, sore throat prior to esophagitis symptoms
  • 20% with oral lesions, 2 with genital, 3 with hand/foot vesicles
  • Classically a distal esophagitis with volcano-like ulceration
  • Immunocytochemistry 83% sensitive
  • Tissue viral culture 96% sensitive
  • Symptoms remit in 2-20 days
  • Antivirals used in 26%, no real ability to determine efficacy