The squamous mucosa is extensively involved by shallow well-demarcated ulcers, seen as whitish lesions on EGD. The intervening mucosa appears relatively normal.
In HSV infection, the edge of the ulcer contains the diagnostic viral inclusions. This corresponding histology of the esophageal squamous epithelium shows numerous squamous cells involved by HSV cytopathic effect - nuclear clearing and multinucleation. An associated neutrophilic inflammatory exudate is obvious as well.
Nuclear enlargement and molding is seen here, along with a "ground glass" chromatin appearance. Thickened nuclear membranes is also a feature.
Herpetic esophagitis overwhelmingly affects the immunocompromised host such as patients with HIV, organ transplantation, or prior chemotherapy. While some may be asymptomatic, many have dysphagia, chest pain, or even upper GI bleeding.
In the immunocompromised host, acyclovir is the treatment of choice