A Case of Asymptomatic Culture Positive Human Simplex Virus Duodenitis Treated with Acyclovir: 1116

Introduction: Acute duodenitis is a common condition often caused by peptic ulcer disease (PUD), of which the most common etiologies are Helicobacter pylori infection and the use of non-steroidal anti-inflammatory drugs (NSAIDs). However, as diagnostic methods have expanded and as technology allows for detection of more subtle lesions, the differential for acute duodenitis continues to expand. While commonly regarded as a source of PUD before the discovery of IH. pylori, infection with viral pathogens has more recently been associated with immunocompromised patients, and rarely seen in otherwise healthy individuals. In particular, reactivation of human simplex virus (HSV) has been infrequently reported, and mainly manifests in the esophagus, rectum, and perineum in immunocompromised patients. We present a case of an 80-year-old immunocompetant female who was incidentally found to have HSV duodentitis on upper endoscopy. Our patient is an 80-year-old woman with a history of a hiatal hernia repair who presented with a 1-year history of intermittent solid food dysphagia, occurring once per month. Aside from globus sensation, her review of systems was unremarkable, including the absence of odynophagia, weight loss, early satiety, abdominal pain, or change in bowel habits. Her medication review was notable for daily aspirin 81 mg. Further evaluation by EGD was performed. Multiple, punched-out, clean-based ulcers without surrounding erythema were visualized in the duodenal bulb, with normal mucosa in the second portion of the duodenum, as well the stomach and esophagus. Mucosal biopsies of the duodenal bulb demonstrated acute duodenitis, and viral culture was positive for herpes simplex virus type I (HSV I). Subsequent immunohistochemical staining of the tissue was negative. Testing for H. pylori, cytomegalovirus (CMV), and human immunodeficiency virus (HIV) was negative. She was never treated with proton pump inhibitor or other antacids, but successfully treated with valacyclovir 1 gram by mouth twice daily for 1 week. Repeat EGD 2 months later demonstrated resolution of duodenitis and healing of her duodenal ulcers. She remained asymptomatic. While immunocompromised patients are commonly susceptible to viral duodenitis, herpes simplex virus is not commonly reported as an etiology of acute duodenitis in the immunocompetent population. This case illustrates a rare cause of duodenal ulceration in an otherwise healthy individual, and should serve to broaden the differential diagnosis of small bowel ulcers and raise awareness of the utility of viral cultures when encountering suspicious appearing lesions. Additionally, this case highlights successful treatment of HSV duodenitis with oral antiviral therapy.