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.
- 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)
- 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.
- 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