What is the recommended treatment for herpetic esophagitis?

Treatment of Herpetic Esophagitis

Intravenous acyclovir at 5-10 mg/kg every 8 hours for 7-14 days is the treatment of choice for herpetic esophagitis in both immunocompromised and immunocompetent patients. 1, 2

Diagnostic Confirmation

• Definitive diagnosis requires endoscopy with biopsy showing histologic evidence of multinucleated giant cells with intranuclear viral inclusions, plus culture confirmation 1
• However, a diagnostic trial of antifungal therapy should be considered first to rule out candidal esophagitis before proceeding to endoscopy, as symptoms can overlap 1
• Endoscopic findings typically show superficial ulcers, most commonly in the distal third of the esophagus 3

Treatment Regimen by Clinical Severity

Standard Herpetic Esophagitis

• Acyclovir 5-10 mg/kg IV every 8 hours for 7-14 days is the recommended regimen 1, 2, 4
• Clinical response is typically dramatic, with symptom improvement within 24-48 hours 5
• IV therapy is necessary for patients with severe disease or those unable to tolerate oral intake 1

Disseminated Disease or CNS Involvement

• Increase dose to 10 mg/kg IV every 8 hours and extend duration to 21 days for disseminated HSV disease or encephalitis 1, 2
• This higher dose and longer duration applies to any patient with evidence of visceral organ involvement beyond the esophagus 1

Immunocompetent Patients

• The same IV acyclovir regimen (5-10 mg/kg every 8 hours) is effective even in immunocompetent patients with severe odynophagia 5
• Oral valacyclovir may be considered in immunocompetent patients with milder disease who can tolerate oral intake 6

Refractory or Recurrent Disease

• For acyclovir-refractory cases, amphotericin B oral suspension (1 mL four times daily of 100 mg/mL suspension) can be considered, though this product is not available in the United States 1
• Patients with frequent severe recurrences (>3-6 episodes per year) should receive chronic suppressive therapy with oral acyclovir 1, 2

Dose Adjustments and Monitoring

Renal Impairment

• Acyclovir requires dose adjustment based on creatinine clearance due to primary renal excretion 1, 2, 4
• For creatinine clearance 15-50 mL/min: reduce frequency or dose proportionally 4
• For anuric patients: half-life increases from 2.5 hours to 19.5 hours, requiring substantial dose reduction 4

Toxicity Monitoring

• Primary toxicities include phlebitis, renal toxicity, nausea, vomiting, and rash 1, 2
• Neutropenia (absolute neutrophil count <1,000/mm³) is a major concern, particularly with high-dose therapy 1, 2
• Monitor renal function and complete blood counts during therapy, especially in patients receiving prolonged treatment 1

Clinical Pearls and Pitfalls

• Odynophagia and chest pain are the hallmark symptoms (present in 88% of cases), not dysphagia alone 3
• Extraesophageal herpes lesions are present in only 38% of patients at diagnosis, so absence of oral or cutaneous lesions does not exclude the diagnosis 3
• Recent predisposing factors such as nasogastric tube placement, steroid therapy, or anticancer therapy are present in approximately 47% of cases 3
• In HIV-infected patients, herpetic esophagitis typically occurs at CD4 counts <50 cells/mm³ (median 15/mm³) 3
• Complete resolution occurs in approximately 80% of treated patients, with partial response in an additional 15% 3