Joyce Chivia and Pedro C. Figueiredo describe a 73-year-old man with bilateral pneumonia and treated with piperacillin and tazobactam. The patient had 2 recent hospital admissions for severe depression with psychotic symptoms, and continued to refuse food and lost weight despite resolution of pneumonia.

The authors performed an upper digestive endoscopy and found numerous scattered and coalescing white plaques in the distal two thirds of the esophagus (see figure). The lesions appeared to be esophageal candidiasis, so the patient was given fluconazole for treatment.

However, analysis of biopsy specimens revealed an ulcerated esophagitis and the presence of herpes viral inclusions. The patient was not infected with HIV or immunocompromised. His symptoms improved after he was given acyclovir, and he was discharged from the hospital.