Infectious esophagitis by papilloma virus. A clinical case

Introduction: The esophagus may be affected by several infective agents, which cause mucosa alterations of various degree, and which can determine either light symptons or critical clinical problems with a high mortality risk. These diseases very often affect patients with reduced immunocompetence. Some of the infectious agents most frequently involved in esophageal infections are Herpes virus, Candida, CMV, HIV. Infectious esophagitis from HPVs are rare in the western countries. The greater number of registered cases have been discovered in the East. Hypotesis is that HPV is a possible etiologic agent in esophageal carcinogenesis, most probaby acting synergistically with physical, chemical, and/or nutritional factors in some high-risk areas of China. Although there are specific endoscopic aspect for infectious esophagitis from different agents, it is difficult to make a differential diagnosis and therefore biopsies, cultures and brushing have a particular importance. The bioptic area is a critical point for histological diagnosis of infectious oesophagitis. Infact, in case of suspected infection from herpes virus, the biopsies must be made on the mucosa surrounding the ulcerative lesion, whereas, for the cytomegalovirus, the specimen must be obteined from the ulcerative crater. Other important procedure, in case of supposed infectiouse disease, is culture, especially with the “shell vial” technique. Epidemiological and experimental evidences suggest the possibility that HPV infection increases the cancer risk for the oral cavity, pharynx and upper aerodigestive tract. However, histologic changes, suggesting HPV infection, are occasionally found adjacent to squamous cell carcinoma or in squamous papilloma of the esophagus, but the relationship between HPV infection and benign and malignant squamous lesions of the esophagus is not yet clear. It is important to differenziate infective esophagitis from gastroesophageal reflux esophagitis in order to perform an up-to-date treatment. Clinical Case: A 25 year old woman was hospitalized in the Federico II University Dept. of General Surgery for arising of retrosternal pain, odynophagia and dysphagia, both for solids and liquids. These symptoms had begun six days before admission. Bioumoral routine tests showed no abnormalities. No pathognomonic symptoms for gastroesophageal reflux nor caustic assumption was referred. The esophago-gastro-duodenoscopy showed, in midium esophagus, a large and deep ulcerative lesion, which involved the whole lumen between 26 and 30 cm. The lesion was thickened and covered by fibrin. Several bioptic tests were performed: IgG anti-varicella-zoster virus, anti-herpes simplex virus, anti-Epstein-Barr-vca were positive. The anti-HIV 1-2 test was negative. No lymphocytic alteration was observed. The histological diagnosis was “active chronic inflammatory infiltration and fibrinoleukocyte exudate”, which is direct sign of ulcerative lesion. Cytologic changes of coilocytic type (giving evidence for HPV infection) were observed. Examination of oral cavity, pharynx and upper respiratory tract gived no evidence of lesions by HPV or other causes. The patient received therapy consisting in mucosal protectives (sucralphate) and Total Parenteral Nutrition. At EGDS, performed two weeks later, the lesion appeared completely healed. References 1. Chang F., Syrjanen S., Shen Q., et al. Evaluation of HPV, CMV, HSV and EBV in esophageal squamous cell carcinomas fom a high-incidence area of China. Anticancer Res 2000 20(5C): 3935-40. 2. Chen L., Yang L., Sun Z. et al. Detection of human papillomaviral infection on Kazakh patients with esophageal squamous cell carcinoma in Xinjiang Chinese Journal of Clinical Oncology 2009; 6 (1): 64-67 3. de Villiers E.M., Lavergne D., Chang F., et al. An interlaboratory study to determine the presence of human papillomaviruses DNA in esophageal carcinoma from China. Int J Cancer 1999; 81(2): 225-8. 4. Franceschi S., Munoz N., Bosch XF et al. Human papillomavirus and cancers of the upper aerodigestive tract: a review of epidemiological and experimental evidence. Cancer Epidemiol Biomarkers Prev 1996; 5 (7): 567-75. 5. Kamangar F., Qiao Y.L., Schiller J.T. et al. Human papillomavirus serology and the risk of esophageal and gastric cancers: Results from a cohort in a high-risk region in China. International Journal of Cancer 2006; 119 (3): 579-584