Atypical presentation of herpes simplex (chronic hypertrophic herpes) in a patient with HIV infection

Herpes hipertrófico perianal tratado eficazmente com imiquimod

“…8 The hypertrophic variant of genital herpes is rare and has been described in the context of immunodepression, particularly in patients with HIV infection and/or immune reconstitution inflammatory syndrome (IRIS). 4,5,7 The reason why this hypertrophic Lestre A B variant appears almost exclusively in patients coinfected by HIV is not totally clear, since there seens to be no correlation with the degree of immunodepression and/or lymphocyte count T CD4+. 5,9,10 Nevertheless, the evolution into hypertrophic forms of genital herpes may be partially justified by immunological deregulation secondary to HIV infection, particularly by: 1) Production of TNF-alpha by an increased number of plasmocytoid dendritic cells factor XIII-positive, promoting the keratinocyte growth rate and consequent acanthosis and hyperkeratosis and 2) Diminution of IFN-gamma production, a cytokine that plays an important regulating role in keratinocyte activity.…”

“…Histologically, variable epidermal hyperplasia can be observed, with multinucleate epithelial cells and dense mixed dermal inflammatory infiltrate composed of lymphocytes, plasmocytes and eosinophils. 4,7 It is recommended to perform an incisional cutaneous biopsy, since small samples may be insufficient for diagnosis and masked by the intense inflammatory response to the virus. 12 The demonstration of the lesional HSV presence may be done through immunohistochemical methods or PCR.…”

“…6 The onset of hypertrophic genital herpes usually occurs in the immunodepression context and it is often resistant to antiviral therapies, with frequent relapses. 4,5,7 The authors report a case of hypertrophic perianal genital herpes …”

“…3 More rarely, pseudo-tumoral hypertrophic forms that simulate squamous cell carcinoma or other viral infections have been described. 4,5 In these cases, a high degree of clinical suspicion is required. The synergism between the HSV and HIV infections is also reflected in the therapeutic approach to genital herpes, particularly in individuals with low lymphocyte T CD4+ counts.…”

Dermatologic Diagnoses in the Perianal Area

“…Histologically one may see changes that are characteristic of HSV infection, but often the only findings are those of pseudoepitheliomatous hyperplasia of the skin, dense inflammatory infiltrates in the dermis, granulation tissue, and fibrosis. This condition is known as pyoderma vegetans 10,11 and it can develop not only in chronic HSV lesions, but also in any chronic ulcerative process in an area prone to secondary bacterial infection, such as the perianal area. Unless the tumor is destroyed by excision, ablation, or cauterization, the ulcers will heal very slowly, in spite of using adequate anti-HSV medications.…”