Herpes esophagitis: sensitivity of double-contrast esophagography

During a 10-year period between 1978 and 1987, there were 25 confirmed cases of herpes esophagitis with positive esophageal brushings, biopsies, and/or cultures for the herpes simplex virus. Eighteen of those patients had double-contrast esophagrams, but two were excluded from our study because they had combined fungal and viral esophagitis. All of the remaining 16 patients were symptomatic, and 14 were immunocompromised. Herpes esophagitis was diagnosed on the original radiographic reports in nine (56%) of those 16 patients. In all nine, double-contrast radiographs revealed discrete, superficial ulcers on a relatively normal background mucosa without significant plaque formation. In the remaining seven patients, double-contrast esophagrams revealed plaquelike lesions that were indistinguishable from those of Candida esophagitis (four cases), thickened folds (two cases), and a giant esophageal ulcer (one case). During the same period, herpes esophagitis was diagnosed on seven other double-contrast esophagrams in which histologic, cytologic, and virologic studies were negative for the herpes simplex virus. However, the endoscopic findings were also suspicious for herpes esophagitis in six of those cases, suggesting that they may represent true-positive cases in which there was inadequate tissue sampling. Thus, our experience indicates that radiographic abnormalities can almost always be detected on double-contrast esophagrams in patients with herpes esophagitis, and in more than 50% of cases, a specific radiographic diagnosis can be made because of discrete ulcers without significant plaque formation.