Esophageal and gastric ulceration due to synchronous herpes simplex virus, cytomegalovirus and Epstein-Barr virus infection

The authors report the case of a man of 71 years-old, with a previous history of type 2 diabetes mellitus, hyper- tension, and renal transplantation in 2013 due to chronic kidney disease. He was under immunosuppression with prednisolone, mycophenolate mofetil and tacrolimus. The patient was admitted by worsening of his health sta- tus lasting for one month, with progressive asthenia, an- orexia weight loss, and marked backache with movement limitation. Analytically he presented with microcytic anemia de novo (hemoglobin 9.6 g/dL), hypoalbumin- emia and a slight increase of liver tests. Initially a thora- co-abdominal computerized tomography was performed and revealed the presence of multiple nodules in the liver parenchyma, suggestive of metastases. In this context it was decided to carry out endoscopic work-up for malig- nancy screening. The upper endoscopy showed two -superficial-and-longitudinal-ulcers-in-the-distal-esophagus and in the gastric antrum there were two other larger ulcers with regular edges (Figs. 1 and 2). Histological evaluation- revealed- the- presence- of- morphological- find- ings compatible with ulcerated lesions (Fig. 3), with immunohistochemical analysis inconclusive for cyto- megalovirus (CMV), while the evaluation by molecular biology (polymerase chain reaction - PCR) strongly positive for herpes simplex virus (HSV) type 1, CMV and Epstein-Barr virus (CMV) synchronous infection. Later it was performed a colonoscopy that revealed the presence of a malignant neoplasm in sigmoid colon, con- firmed-after-histological-evaluation.-The-patient-was-then referred for symptomatic treatment.