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Tomaino MV, Sanchez Costantini M, Alfaro CT. Pseudotumoral herpes genitalis in a woman living with HIV: Diagnosis and treatment challenges. Int J STD AIDS 2024; 35:405-408. [PMID: 38031871 DOI: 10.1177/09564624231218759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Herpes simplex virus (HSV) is the leading cause of genital ulcers worldwide. In rare cases, mostly among immunocompromised hosts, HSV infections can present as hypertrophic pseudotumoral forms simulating malignancies or often mistaken as other viral infections, usually resistant to conventional antiviral therapy and often requiring alternative therapeutic approaches. A high level of clinical suspicion is needed. We present a case of woman living with HIV with pseudotumoral vulvar herpes refractory to oral acyclovir, successfully treated with systemic foscarnet and topical imiquimod.
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Affiliation(s)
- María V Tomaino
- Infectious Diseases Division, Hospital Nacional Alejandro Posadas, El Palomar, Argentina
| | | | - Carmen T Alfaro
- Pathology Division, Hospital Nacional Alejandro Posadas, El Palomar, Argentina
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Sachan S, Potluri VK, Gopinath H, Sravanthi KL, N P, Bharti JN, Haritha T. Recalcitrant ulcerative genital herpes in an immunocompetent individual treated successfully with imiquimod. Int J STD AIDS 2024; 35:231-233. [PMID: 37938029 DOI: 10.1177/09564624231213110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND This case report describes the successful use of imiquimod to treat genital herpes in an immunocompetent individual with acyclovir-resistant HSV. CASE REPORT A 32 year old male patient, presented with asymptomatic non-healing ulcers over the genital region for 2 years. The ulcers initially responded to acyclovir but became persistent after a few months. He also received multiple courses of antibiotics. On examination, the patient had bilateral inguinal lymphadenopathy and multiple painless ulcers over the coronal sulcus. Routine investigations were normal. The patient was treated with oral and intravenous acyclovir but showed no response. He was then started on topical imiquimod cream applied on alternate days. After one week, the patient presented with pain, redness, burning sensation, and fresh ulcer over the glans which were suspected to be imiquimod-induced irritant reaction or ulcer. Imiquimod was withheld for one week and then restarted at a twice-weekly schedule. After 1 month and 7 days of treatment with imiquimod at a twice-weekly schedule, there was healing of the ulcers. CONCLUSION This case report illustrates the efficacy of imiquimod cream as a topical treatment for genital herpes simplex in an immunocompetent patient who had previously been unresponsive to treatment with acyclovir.
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Affiliation(s)
- Suvigya Sachan
- Senior Resident, Department of Dermatology, AIIMS Mangalagiri, Mangalagiri, India
| | - Vijay Kiran Potluri
- Non Academic Junior Resident, Department of Dermatology, AIIMS Mangalagiri, Mangalagiri, India
| | - Hima Gopinath
- Associate Professor, Department of Dermatology, AIIMS Mangalagiri, Mangalagiri, India
| | - Kode Leela Sravanthi
- Senior Resident, Department of Dermatology, AIIMS Mangalagiri, Mangalagiri, India
| | - Prabhakaran N
- Assistant Professor, Department of Dermatology, AIIMS Mangalagiri, Mangalagiri, India
| | - Jyotsna Naresh Bharti
- Additional Professor and HOD, Department of Pathology, AIIMS Mangalagiri, Mangalagiri, India
| | - Thiruveedhula Haritha
- Additional Professor and HOD, Department of Dermatology, AIIMS Mangalagiri, Mangalagiri, India
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Sun J, Malhotra R, Ananthakrishnan L, Gopal P. Herpes Proctitis in Men Mimicking Rectal Adenocarcinoma: Two Cases of an Easily Overlooked Diagnosis in the Proximal Rectum. Case Rep Pathol 2023; 2023:6947960. [PMID: 37545540 PMCID: PMC10400295 DOI: 10.1155/2023/6947960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 05/09/2023] [Accepted: 05/13/2023] [Indexed: 08/08/2023] Open
Abstract
We describe two cases of rectal herpes simplex virus (HSV) infection in men that clinically mimicked rectal adenocarcinoma. Herpes infection in this location more commonly presents as an anal mass with viral inclusions in squamous epithelial cells. We report these cases to increase awareness of the unusual presentation as a proximal rectal mass with viral inclusions in endothelial cell nuclei. One patient was HIV-positive, and the other one had a history of having sex with men (MSM). Both patients had a thickened rectal wall with prominent lymphadenopathy on computed tomography (CT) scan, suspecting for malignancy. Biopsy showed abundant granulation tissue, necrosis, and inflammatory infiltrate composed predominantly of lymphocytes with admixed numerous plasma cells, eosinophils, and neutrophils. Rare granulation tissue vessels were lined by endothelial cells with nuclear molding and chromatin margination, and nuclei that were positive for HSV immunohistochemistry (IHC). One patient had confirmatory viral culture from biopsy of the ulcerated rectal mass. Both patients had symptom resolution following treatment for HSV. HSV should be considered in the differential diagnosis of rectal inflammatory masses, particularly in immunocompromised, HIV-positive, and MSM patients.
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Affiliation(s)
- Jing Sun
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Purva Gopal
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Levett K, Youngs J, Hoppenot C, Masand RP. Herpesvirus Infection Masquerading as a Neoplasm in an HIV-Positive Patient: A Potential Diagnostic Pitfall. Am J Dermatopathol 2023; 45:333-336. [PMID: 36939122 DOI: 10.1097/dad.0000000000002402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
ABSTRACT Herpesvirus infection classically presents as a clustered, vesicular rash over mild erythema. However, unusual presentations may mimic tumors and be a potential pitfall. We describe the case of a 55-year-old HIV positive woman with this unusual manifestation of a common disease which was initially diagnosed as a benign neoplasm. Review of pathology revealed histologic features characteristic of this form of herpesvirus eruption. Awareness of this rare clinical and microscopic presentation is important to guide appropriate use of immunostains, prevent misdiagnosis, and promptly institute of antiviral therapy.
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Affiliation(s)
| | | | - Claire Hoppenot
- Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
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Folch H, Jahr C, Giacaman P, Zuñiga P, Del Pino M. Hypertrophic genital herpes simplex due to HSV 2 sensitive to maximum dose of oral aciclovir. Clin Exp Dermatol 2023; 48:43-44. [PMID: 36631433 DOI: 10.1093/ced/llac014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/27/2022] [Accepted: 10/13/2022] [Indexed: 01/13/2023]
Abstract
In patients who are HIV-positive, genital herpes simplex virus (HSV) infections can present with atypical clinical presentations, representing a diagnostic challenge. Hypertrophic herpes simplex has been classified as a clinical presentation that generally tends to be resistant to treatment with aciclovir. We present a case of hypertrophic HSV due to HSV Type 2, which was sensitive to maximum doses of oral aciclovir.
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Affiliation(s)
- Hugo Folch
- Department of Dermatology, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Catalina Jahr
- Department of Dermatology, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Paula Giacaman
- Department of Dermatology, Hospital San José, Santiago, Chile
| | - Priscila Zuñiga
- Department of Dermatology, Hospital Clínico Universidad de Chile, Santiago, Chile
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Khellaf L, Bouscarat F, Burrel S, Fidouh N, Hachon L, Bucau M, Lariven S, Boutolleau D, Joly V, Ghosn J, Le Pluart D, Thy M. Novel mutations in antiviral multiresistant HSV-2 genital lesion: A case report. J Med Virol 2022; 94:6122-6126. [PMID: 35973907 DOI: 10.1002/jmv.28070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/02/2022] [Accepted: 08/15/2022] [Indexed: 01/07/2023]
Abstract
HSV-2 antiviral resistance mainly occurs in immunocompromised patients and especially in HIV-positive individuals receiving long-term antiviral treatment. Those situations can be challenging as few alternatives are available for HSV infection management. To describe clinical and virological significance of two novel potential HSV-2 resistance mutations after treating an obese patient with a pseudotumoral genital HSV-related lesion. Consecutive different antiviral treatments were used: valacyclovir (VACV) then foscarnet (FOS) then topical cidofovir (CDV) and finally imiquimod. Under VACV, genotypic resistance testing revealed a novel mutation within viral thymidine kinase (TK, gene UL23) not previously reported but probably accounting for antiviral resistance: W89G, similar to W88R mutation reported in HSV-1 TK, known to be associated with ACV resistance for HSV-1. Under FOS, while initial mutations were still present, a second genotypic resistance testing performed on persisting lesions showed a novel mutation within viral DNA polymerase (DNA pol, gene UL30): C625R. All three antivirals used in this case are small molecules and pharmacokinetics of VACV, FOS, and CDV have not been evaluated in animals and there are very few studies in human. As small molecules are poorly bound to proteins and distribution volume is increased in obese patients, there is risk of underdosage. This mechanism is suspected to be involved in emergence of resistance mutation and further data is needed to adapt, closely to patient profile, antiviral dosage. This report describes a chronic HSV-2 genital lesion, with resistance to current antivirals and novel mutations within viral TK and DNA pol which may confer antiviral resistance.
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Affiliation(s)
- Lucas Khellaf
- Department of Infectious Diseases, Hôpital Bichat, Université de Paris, Paris, France
| | - Fabrice Bouscarat
- Department of Dermatology, Hôpital Bichat, Université de Paris, Paris, France
| | - Sonia Burrel
- Department of Virology, Centre National de Référence Herpès virus, Hôpital Pitié-Salpétrière, Sorbonne Université, INSERM U1136, Institut Pierre Louis d'épidémiologie et de santé publique (IPLESP), Paris, France
| | - Nadhira Fidouh
- Department of Virology, Hôpital Bichat, Université de Paris, Paris, France
| | - Lorry Hachon
- Department of Pharmacy, Hôpital Bichat, Université de Paris, Paris, France
| | - Margot Bucau
- Department of Pathology, Hôpital Bichat, Université de Paris, Paris, France
| | - Sylvie Lariven
- Department of Infectious Diseases, Hôpital Bichat, Université de Paris, Paris, France
| | - David Boutolleau
- Department of Virology, Centre National de Référence Herpès virus, Hôpital Pitié-Salpétrière, Sorbonne Université, INSERM U1136, Institut Pierre Louis d'épidémiologie et de santé publique (IPLESP), Paris, France
| | - Véronique Joly
- Department of Infectious Diseases, Hôpital Bichat, Université de Paris, Paris, France
| | - Jade Ghosn
- Department of Infectious Diseases, Hôpital Bichat, Université de Paris, Paris, France
| | - Diane Le Pluart
- Department of Infectious Diseases, Hôpital Bichat, Université de Paris, Paris, France
| | - Michaël Thy
- Department of Infectious Diseases, Hôpital Bichat, Université de Paris, Paris, France
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Muacevic A, Adler JR. Hypertrophic Perianal Herpes Mimicking Squamous Cell Cancer: A Case Report and a Review of the Literature. Cureus 2022; 14:e30649. [PMID: 36439566 PMCID: PMC9684622 DOI: 10.7759/cureus.30649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 12/03/2022] Open
Abstract
Clinical practice frequently involves the discovery of perineal lesions. The human papillomavirus, molluscum contagiosum, and herpes simplex virus are to blame for the majority of these anogenital lesions. In the majority of cases, these lesions may be identified by their distinctive appearance. It is challenging to make a clinical diagnosis in immunocompromised people since these lesions might be large and have uncommon appearances. Verrucous perianal herpes is a rare type of herpes that resembles squamous cell carcinoma in gross appearance. We present a case of a 71-year-old man on azathioprine, an immunosuppressive drug for autoimmune pancreatitis, who developed a perianal lesion resembling squamous cell carcinoma. Excisional biopsy revealed a benign ulcerative lesion with herpetic inclusions. The patient received antiviral treatment, and the perianal wound completely healed. He developed a similar lesion in the perineum at one year follow up, which was successfully treated with oral and topical antivirals.
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Leeyaphan C, Nanchaipruek Y, Phinyo P. Therapeutic outcomes and prognostic factors in patients with hypertrophic herpes simplex infection treated with imiquimod: A systematic review and meta-analysis of individual patient data from case reports and case series. J Dermatol 2022; 49:879-886. [PMID: 35632986 DOI: 10.1111/1346-8138.16446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/22/2022] [Accepted: 05/05/2022] [Indexed: 11/26/2022]
Abstract
Hypertrophic herpes simplex (HHS) often has atypical presentations, such as a hypertrophic mass or ulcers, with chronic courses. This situation poses a diagnostic challenge and results in delayed treatment. Imiquimod was used as a treatment for HHS by several studies, but the therapeutic outcomes varied. This systematic review and meta-analysis of individual patient data was conducted to investigate the therapeutic outcomes and prognostic factors of imiquimod treatment for patients with HHS. Biomedical databases (Embase, PubMed, Medline, Cochrane Controlled Trials Register, and ClinicalTrials.gov) were searched for all types of clinical studies reporting the complete cure rate and the time to complete response to imiquimod therapy between 1926 and 2021. Quantitative analysis of individual patient data was performed using multivariable flexible parametric survival regression with cluster variance correction. A total of 12 019 articles were identified and screened for eligibility. Twenty-five studies (21 case reports and four case series) with a combined total of 42 patients were included. The complete cure rate for imiquimod treatment was estimated at 88.1%. The median time to complete response was 60 days (95% confidence interval 35-70). Combined treatment, male sex, and an age less than 50 years were identified as significant prognostic factors for a shorter time to complete cure. A severe local reaction was reported in 2.3%. Imiquimod therapy has high effectiveness and safety in curing HHS. Patients who were male or younger than 50 years or whose treatments were combined with thymidine kinase-dependent antivirals had the best prognoses and were more likely to respond to treatment.
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Affiliation(s)
- Charussri Leeyaphan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yanisorn Nanchaipruek
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Musculoskeletal Science and Translational Research, Chiang Mai University, Chiang Mai, Thailand
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Hu J, Krauss JC, Moyal-Barracco M, Washer LL, Haefner HK, Parker-Featherstone E. Vulvar pseudotumoral acyclovir-resistant herpes in an HIV-negative, non-immunosuppressed patient: A therapeutic challenge. Int J Womens Dermatol 2022; 7:731-736. [PMID: 35028373 PMCID: PMC8714585 DOI: 10.1016/j.ijwd.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/13/2021] [Accepted: 06/16/2021] [Indexed: 11/19/2022] Open
Abstract
Background Vulvar pseudotumoral herpes infections have been reported in HIV-positive patients. A 32-year-old HIV-negative woman presented with a 6-month history of a vulvar pseudotumor that had been unresponsive to oral acyclovir and valacyclovir, as well as topical imiquimod. Objective This study aimed to evaluate the therapeutic efficacy of a multidrug regimen for vulvar pseudotumor herpes infection in an HIV-negative patient. Methods Histology revealed multinucleated giant cells, consistent with a herpes infection. The patient's herpes simplex virus type 2 was resistant to acyclovir. Immunomodulatory agents (thalidomide and topical imiquimod) were started. Results The lesion enlarged after 6 weeks of treatment. Topical cidofovir 1% gel was added. There was gradual decrease in the pseudotumor size. After 7 months, the Pseudotumor had resolved. Conclusion This is the first reported case of vulvar pseudotumoral herpes in an immunocompetent, HIV-negative patient. Oral thalidomide, in association with topical imiquimod and topical cidofovir, was effective in treating acyclovir-resistant pseudotumoral herpes of the vulva.
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Affiliation(s)
- Jun Hu
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - John C. Krauss
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | | | - Laraine L. Washer
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Hope K. Haefner
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, Michigan
| | - Ebony Parker-Featherstone
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, Michigan
- Corresponding author.
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