Genital and Perianal Herpes Simplex Simulating Neoplasia in Patients with AIDS

Abstract

Genital and perianal herpetic ulcers are common in HIV-infected patients and chronic mucocutaneous ulcers persisting for more than 1 month are the hallmark of active AIDS status. However, atypical clinical manifestations of herpes simplex virus (HSV) may occur in immunocompromised patients presenting as tumor-like nodules or condylomatous or hypertrophic lesions, rather than a classic ulcer. Such unusual presentations raise the risk of misdiagnosis and a delay in appropriate treatment. Here we describe nine immunocompromised HIV-positive patients with CD 4 count ranging from 14-362/mm(3) (mean 170/mm(3)), with unusual tumoral presentation of anogenital herpes. There were six male and three female patients with AIDS with mean duration of HIV infection of 14 years. All of the patients had history of highly active antiretroviral therapy (HAART), with five patients compliant with the therapy at the time of biopsy. Six patients presented with scrotal or vulvar masses and three with perianal nodules. Five patients had adjacent human papilloma virus (HPV)-related lesions. Prior to excision, herpetic lesion was clinically suspected in only three patients and in the rest of the patients a malignant growth was the main clinical concern. The predominant histopathologic finding was dense dermal plasmacytic infiltration with overlying pseudoepitheliomatous hyperplasia, superficial ulcers and classic herpetic inclusions. Patients with AIDS may experience excessive number and size of both primary and reactivated herpetic lesions. The tumoral presentations discussed here are less common, but are often clinically misdiagnosed. It is important to be aware of these unusual presentations to provide a correct diagnosis and prompt, effective treatment for HSV. Several studies suggest that aggressive treatment of HSV in combination with HAART therapy provides a significant survival benefit. Pathobiology mechanisms of unusual and exaggerated tumor-like inflammatory response are not completely elucidated.

Chronic mucocutaneous herpes simplex virus and varicella zoster virus infections

“…Wart-like CHSV and CVZV infections may mimic a number of benign or malignant growths, 61,107 including keratoacanthoma, HPV-related verrucous lesions, 93 condylomata acuminata and lata, 66 basal cell carcinoma, 82 verrucous carcinoma, 101 and squamous cell carcinoma. 56,57 Ulcerative CHSV and CVZV may resemble other ulcerations, including genital herpes, CMV-related ulcerations, perianal longstanding herpes in bedridden patients, 109 Hailey-Hailey disease, pemphigus vulgaris, syphilis, Haemophilus ducreyi, extraintestinal Crohn's disease, rectocolitis, and Behçet disease.…”

An unusual hypertrophic genital mass lesion—A diagnostic and treatment dilemma

“…1 However, atypical, fungating vulval lesions due to HSV are rare but have been reported. [1][2][3][4][5][6] HSV lesions may present as large fungating, hypertrophic lesions that present both diagnostic and treatment challenges and may necessitate repeated biopsies and cultures. 3 In this patient, the initial punch biopsy of the vulval mass revealed herpes simplex infection.…”

“…Other forms of therapy have included the use of imiquimod 6 and surgical excision with oral acyclovir. 1 Studies have suggested that hypertrophic genital lesions due to HSV may be related to acyclovir resistance. 1,2 In this case study, a moderate response was seen when intravenous acyclovir was used.…”

“…1 Studies have suggested that hypertrophic genital lesions due to HSV may be related to acyclovir resistance. 1,2 In this case study, a moderate response was seen when intravenous acyclovir was used. Treatment with oral acyclovir did not show any response.…”

Successful treatment of hypertrophic herpes simplex genitalis in HIV‐infected patient with topical imiquimod

“…3 The presence of HSV in the lesion can be demonstrated either by immunohistochemistry, direct immunofluorescence, viral cultures or molecular biology techniques.…”