Esophagitis in a Post-Liver Transplant Patient: A Case of Cytomegalovirus and Herpes Simplex Virus-1 Coinfection

In post-liver transplant patients, esophagitis presents a diagnostic and management challenge due to the potential for opportunistic infections. This case describes a 59-year-old female with primary sclerosing cholangitis who underwent orthotopic liver transplantation six years prior. She presented with dysphagia, and her medical history included immunosuppression with prednisone, tacrolimus, and mycophenolate and a history of achalasia treated with esophageal peroral endoscopic myotomy. Esophagogastroduodenoscopy (EGD) revealed severe esophagitis with extensive ulcerations, raising suspicion for infectious etiologies such as cytomegalovirus (CMV) and herpes simplex virus-1 (HSV-1). The biopsy confirmed a rare coinfection of CMV and HSV-1, which was characterized histologically by viral cytopathic effects and immunohistochemical staining. Treatment with valganciclovir and temporary cessation of mycophenolate led to symptom resolution and viral clearance. Follow-up EGD demonstrated healing of esophageal ulcers, with subsequent findings of Candida esophagitis but no evidence of CMV or HSV recurrence. This case highlights the importance of early endoscopic evaluation and biopsy in immunocompromised patients with esophagitis. CMV and HSV-1 coinfection, while rare, should be considered in this population due to its association with severe complications such as perforation and bleeding. Timely antiviral therapy and immunosuppression adjustment are critical for favorable outcomes.