A 44-year-old man with longstanding AIDS, non-adherent to antiretrovirals (ARVs) and opportunistic infection prophylaxis, presented with 2 months of painful groin nodules. Examination revealed firm, exophytic nodules with purulent drainage from the groin to the base of the penis. Testing for gonorrhea, chlamydia and syphilis was negative. Biopsy revealed ulceration with underlying granulation tissue with chronic inflammatory infiltrate including plasma cells, lymphocytes, eosinophils, and histiocytes. T-cell gene rearrangement was negative, and stains/cultures for acid-fast bacilli, fungi, and bacteria were unrevealing. Viral culture was positive for herpes simplex virus (HSV) resistant to acyclovir (Fig. 1).
Figure 1.
Firm, pink, exophytic nodules with adherent yellow crust located in the right groin.
Herpes vegetans is an atypical presentation of HSV seen in the setting of immunodeficiency, most commonly AIDS.1 Differential diagnosis of ulcerated genital nodules in immunocompromised patients includes condyloma acuminata, condyloma lata, verrucous carcinoma, pemphigus vegetans, or a deep fungal or mycobacterial infection. Biopsy for histology and culture is necessary for workup of this differential, as superficial viral cultures of nodules are often negative.2 Interestingly, in the setting of verrucous or vegetative presentation of HSV, acyclovir resistance is often present.3 Treatment of acyclovir-resistant HSV usually consists of intravenous administration of foscarnet, though alternatives include topical trifluridine, cidofovir, or imiquimod, or intralesional cidofovir.4 This patient was successfully treated with foscarnet.
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Conflict of Interest
The authors declare that they have no conflict of interest.
References
- 1.Castro KG, Ward JW, Slutsker L, et al. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. Clin Infect Dis. 1993;17(4):802–810. doi: 10.1093/clinids/17.4.802. [DOI] [Google Scholar]
- 2.Patel AB, Rosen T. Herpes vegetans as a sign of HIV infection. Dermatol Online J. 2008;14(4):6. [PubMed] [Google Scholar]
- 3.Bae-Harboe YS, Khachemoune A. Verrucous herpetic infection of the scrotum and the groin in an immuno-competent patient: Case report and review of the literature. Dermatol Online J. 2012;18(7):7. [PubMed] [Google Scholar]
- 4.Wanat KA, Gormley RH, Rosenbach M, Kovarik CL. Intralesional cidofovir for treating extensive genital verrucous herpes simplex virus infection. JAMA Dermatol. 2013;149(7):881–883. doi: 10.1001/jamadermatol.2013.4014. [DOI] [PubMed] [Google Scholar]