Odynophagia, dysphagia, and chest pain are recognized as initial symptoms of infectious esophagitis. Singultus is not. We report a case in which the investigation of isolated persistent singultus led to the diagnosis of herpetic esophagitis.

A 47-year-old man was evaluated for renal allograft rejection 6 years after he received a renal transplant for chronic glomerulonephritis. The transplanted kidney functioned well for 3 years until chronic rejection led to gradual loss of function. When renal failure developed, peritoneal dialysis was started and immunosuppressive drugs were tapered. Three weeks later fever, chills, diaphoresis, hematuria, dysuria, oliguria, and allograft tenderness developed in the patient. When empiric therapy for urinary tract infection failed, removal of the transplanted kidney was recommended.

The patient appeared mildly ill during the physical examination. Vital signs were as follows: temperature, 37.7 °C; blood pressure, 160/80 mm/Hg; pulse, 85 beats/min; respiratory rate, 20. He had no oropharyngeal lesions or cervical adenopathy. The chest and abdominal examinations were normal. The allograft site was tender. The peritoneal dialysis catheter site appeared uninfected, and the dialysate was clear. Urine and blood cultures were negative. The patient had a nephrectomy, and acute and chronic rejection were confirmed on histopathologic examination of the allograft.

The patient felt well, except for intractable singultus with two to three hiccups per minute that developed immediately after surgery. He had no chest pain, dysphagia, odynophagia, or fever. Nine days after the nephrectomy, an upper endoscopy showed exudative lesions with friable plaques overlying shallow esophageal ulcerations.

The biopsy result was consistent with herpes simplex virus, and cultures were positive for herpes simplex virus type I. Acyclovir was then started. The singultus resolved after 2 days of intravenously administered acyclovir.

Herpetic esophagitis with the initial symptom of, or associated with, singultus has not been previously reported [1]. Infectious esophagitis has been reported in 24% of renal transplant recipients [2]. Five percent of these patients had herpetic infections. In patients having liver transplants, esophagitis is caused by cytomegalovirus and herpes simplex virus in 4% and 6% of patients, respectively [2]. The most common initial symptoms reported in these patients have been dysphagia, epigastric pain, or odynophagia [2], which were absent in our patient.

Because of the potentially serious complications of herpetic esophagitis, early diagnosis and intervention is important [3]. We recommend that immunocompromised hosts developing intractable singultus have upper endoscopy for assessment of infectious esophagitis.