Common causes of ulceration:
- Common in HIV/AIDS (immunocompromised) patients
- Described as yellow plaques, patches or exudates or ulcerations on endoscopy.
- Presence of fungal forms with pseudohyphae (represents invasion).
NOTE: Budding yeast often represent an oral contamination and NOT true candidiasis.
- Special stains (PAS/AB & GMS) can be performed if fungi are not seen on H&E and are advised in the following cases:
1. A clinical impression of candidiasis
2. Striking acute inflammation
3. Prominent parakeratosis
4. Clinical history of refractory GERD or EoE
Herpes simplex virus (HSV)
- HSV infects squamous epithelium, thus seen more commonly at the periphery of the ulcer
- Described as "volcano ulcers" on endoscopy
- 3Ms: Margination of chromatin, Molding of nuclear contours, Multinucleation.
- Cowdry A inclusions (intranuclear WITH clear halo).
- Cowdry B inclusions (intranuclear withOUT halo)
HSV is commonly found at the periphery of an ulcer. Careful examination of any ulcer for HSV, CMV or fungal elements is highhly recommended!! Keep in mind that you can have coinfections in the same patient!
The findings can be very subtle. Careful examination is prudent!
- You can perform a HSV immunostain if no classic viral cytopathic effect is seen on H&E. Recommended in any case of esophageal ulceration as the diagnostic features can be easily obscured by the intense background inflammation.
- Endoscopic findings: linear, serpiginous ulcerations in the distal esophagus-Infects endothelial cells, columnar epithelium and stromal cells, thus seen more commonly in the ulcer base
- "Owls eye" nuclear and cytoplasmic viral inclusions with nuclear & cellular enlargements- Background of mononuclear (lymphocytic) inflammation
Can perform CMV immunostain if no classic viral cytopathic effect seen on H&E. Recommended in any case of esophageal ulceration as the diagnostic features can be easily obscured by the intense background inflammation.
Histology Images: Atlas of Gastrointestinal Pathology. Christina Arnold. Esophagus Chapter- Acute Esophagitis.