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  Table of Contents  
LETTER TO EDITOR
Year : 2019  |  Volume : 40  |  Issue : 1  |  Page : 80-81
 

Extensive vulval and perianal ulceration due to genital herpes virus infection


1 Department of Dermatology, Venereology and Leprosy, Smt. NHL Municipal Medical College, V.S. Hospital, Ahmedabad, Gujarat, India
2 Department of Dermatology, Venereology and Leprosy, GMERS, Gandhinagar, Gujarat, India
3 Department of Dermatology, Venereology and Leprosy, Civil Hospital, Ahmedabad, Gujarat, India

Date of Web Publication10-May-2019

Correspondence Address:
Dr. Santoshdev Pitamber Rathod
Department of Dermatology, Venereology and Leprosy, Smt. NHL Municipal Medical College, V.S. Hospital, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijstd.IJSTD_71_18

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How to cite this article:
Rathod SP, Padhiar B, Shah B. Extensive vulval and perianal ulceration due to genital herpes virus infection. Indian J Sex Transm Dis 2019;40:80-1

How to cite this URL:
Rathod SP, Padhiar B, Shah B. Extensive vulval and perianal ulceration due to genital herpes virus infection. Indian J Sex Transm Dis [serial online] 2019 [cited 2019 Jul 22];40:80-1. Available from: http://www.ijstd.org/text.asp?2019/40/1/80/256247


Sir,

Genital herpes simplex virus type 2 (HSV-2) ulcers occur frequently in people living with HIV/AIDS (PLHIV). Atypical manifestations of HSV-2 infection presenting as extensive, hypertrophic, or vegetating ulcers have been described.[1],[2] However, to understand that how extensive the ulcer produced by HSV can be? We are reporting a case of PLHIV female who presented with large ulcers of size approximating 40 cm × 20 cm.

A 27-year-old female was referred to dermatology outpatient unit of a tertiary medical center in western India from a surgery department to evaluate extensive, painful ulceration involving mons pubis, female genitalia, and perianal region for 2 weeks. The patient was seroreactive for HIV seropositive. Her husband was also seroreactive. The patient denied any history of prior genital ulcerative disease and trauma to the region. Chief complaints were extreme burning after urination and defecation.

Clinical examination revealed two large ulcers. The largest ulcer had well-defined border, irregular shape extending from over the mons pubis in continuity with both labia majora and perineal region and beyond anal orifice totaling approximately 40-cm long and 20-cm wide at the widest point. Erosion was erythematous and at places was covered with seropurulent discharge. Edges of the ulcer were sharply defined and were slopping inward. There was presence of two satellite, vesiculopustular lesions of approximately 0.5 cm × 1 cm size. The smaller ulcer was of annular configuration and was present over the lumbosacral region just lateral to the midline of about 6 cm × 10 cm size also showing few satellite vesiculopustular lesions [Figure 1] and [Figure 2]. Extensive genital ulcer secondary to herpes virus, pyoderma gangrenosum, and ulcerative variant of lupus vulgaris was kept as differential diagnosis.
Figure 1: Well-defined, superficial erythematous erosion with slightly raised edges; the floor of the ulcer is covered with seropurulent discharge and shows areas of healing in-between lying over the pubic symphysis. Two satellite vesiculopustules are seen just above the ulcer margin

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Figure 2: Well-defined, superficial erythematous erosion with slightly raised edges; the floor of the ulcer is covered with seropurulent discharge and shows areas of healing in-between lying over the pubic symphysis and extending in continuity up to both labia majora and fourchette involving perineum as well

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On palpation; bilateral, painful inguinal lymphadenopathy was present. The patient was on antiretroviral therapy (three drug regimens comprising zidovudine, lamivudine, and nevirapine). CD4 count of the patient was 144 cells/mm3 at the time of ulcer episode. The patient was diagnosed with HIV before 2 years. Tzanck smear prepared from vesicular lesion showed multinucleated giant cells [Figure 3]. Mantoux test was negative. Pathergy test was negative. Culture for HSV and ELISA for anti-HSV 1 and 2 antibodies was not performed due to lack of facility at the treating institute. Based on clinical presentation and Tzanck smear examination, provisional diagnosis of extensive genital and perianal ulceration due to HIV was kept, and the patient was treated with tablet aciclovir 400 mg three times a day for 2 weeks along while antiretroviral therapy was continued. At the end of 2 weeks, entire erosion healed with hypopigmentation and few areas within the healed lesion showing follicular re-pigmentation [Figure 4].
Figure 3: Tzanck smear preparation showing multinucleated giant cells

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Figure 4: Complete healing of the lesion after 2-week therapy with tablet aciclovir 400 mg three times a day. There is postinflammatory hypopigmentation with some areas within the lesion showing follicular re-pigmentation

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We report this case to highlight the extensive ulceration produced by HSV infection in PLHIV which may mimic widespread superficial soft-tissue infection and may appear gangrenous, pyoderma gangrenosum- like[3], lupus vulgaris. As herpes genitalis often assumes above mentioned unusual presentations in seropositive individuals, its diagnosis is difficult in context of seropositive patients. Simple awareness of this condition in context of HIV can prevent unnecessary antibiotic use and surgical dressing. HSV reactivation is more frequent despite the patient being on antiretroviral therapy.[4] Tzanck smear still remains an useful bedside investigation in resource-limited setting to confirm the diagnosis of HSV infection.[5] However, histopathology can be helpful in cases where Tzanck smear is negative.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Simonsen M, Nahas SC, Silva Filho EV, Araújo SE, Kiss DR, Nahas CS, et al. Atypical perianal herpes simplex infection in HIV-positive patients. Clinics (Sao Paulo) 2008;63:143.  Back to cited text no. 1
    
2.
Sarna J, Sharma A, Naik E, Toney J, Marfatia YS. Protean manifestations of herpes infection in AIDS cases. Indian J Sex Transm Dis 2008;29:26-8.  Back to cited text no. 2
  [Full text]  
3.
Kumar L S, Shanmugasekar C, Lakshmi C, Srinivas CR. Herpes misdiagnosed as pyoderma gangrenosum. Indian J Sex Transm Dis 2009;30:106-8.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Yudin MH, Kaul R. Progressive hypertrophic genital herpes in an HIV-infected woman despite immune recovery on antiretroviral therapy. Infect Dis Obstet Gynecol 2008;2008:592532.  Back to cited text no. 4
    
5.
Durdu M, Baba M, Seçkin D. The value of Tzanck smear test in diagnosis of erosive, vesicular, bullous, and pustular skin lesions. J Am Acad Dermatol 2008;59:958-64.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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