International Journal of sro & AIDS 1992: 3: 442-444
CASE REPORT
Atypical presentations of herpes simplex virus infection Jyoti Dhar MRCP, P B Carey MRCP and A B Alawattegama MRCOG University Department of Genitourinary Medicine, Royal Liverpool Hospital, Prescot Street, Liverpool L7 8XP, UK Keywords: Genital herpes, eczema herpeticum, mucocutaneous lesions, recurrent attacks, cellulitis
Herpes simplex virus (HSV) infection has been medically recognized for several centuries and affects close to 100% of individuals in certain population groups 1. The clinical presentation of genital herpes varies greatly depending partly on whether it is a primary or a recurrent infection. Irritation, pain, dysuria, urethral discharge and tender non-suppurative inguinal lymphadenopathy are the predominant local symptoms associated with vesicular or ulcerative lesions as the presenting clinical features-. We report two patients with unusual presentations recently seen in the Department of Genitourinary Medicine at the Royal Liverpool Hospital. Figure 1. Case 1: bilateral conjunctivitis, periorbital and palpebral oedema with pus exuding from cracked, ulcerated and crusted eyelids
CASE REPORTS
Case 1
AR, a 36-year-oldCaucasian, quality control engineer, in a monogamous relationship was referred to the clinic with a history of a flu-like illness followed 2 weeks later by dysuria, tenderness of the glans penis, anal discomfort and an ulcer near the left ear. In the previous 5 days he had received treatment for an infection of the left eye with amoxycillin and an eye ointment, and clotrimazole cream for local application to the glans penis, by his general practitioner. Except for a past history of herpes labialis, his health before this illness had been excellent. Physical examination revealed a febrile patient with erosions on the forehead, severe bilateral conjunctivitis, marked periorbital and palpebral oedema with pus exuding from cracked, ulcerated and crusted eyelids (Figure 1). There was evidence of healed angular cheilitis and mild glossitis. There were multiple tender erosions of the prepuce and a bleeding ulcer on the glans penis (Figure 2). The prepuce, although phimotic, was retractable. There were extensive anal and perianal vesicles and ulcers. Correspondence to: Dr J Dhar. University Department of Genitourinary Medicine, Royal Liverpool Hospital, Prescot Street, Liverpool L7 8XP, UK
There were no other mucocutaneous lesions and the systemic examination was normal. An ophthalmological opinion revealed bilateral dendritic ulcers with a few cells in the anterior chamber and secondary iritis of the left eye. These findings suggested extensive mucocutaneous HSV infection and the patient was admitted to hospital. Laboratory investigations revealed normal full blood count with an elevated erythrocyte sedimentation rate at 60 mm/1st hour. HSV type 1 was cultured from swabs taken from the eyes and the anal and perianal areas. In addition, Staphylococcus aureus was grown from the eyes and the urine showed macroscopic haematuria with some hyaline and granular casts. No pathogens were isolated from the urine and cytological assessment for malignant cells was negative. Serological tests for syphilis, hepatitis B and human immunodeficiency virus (HIV) infection were negative as were tests for autoantibodies and cytomegalovirus. Serum immunoglobulin and CD4 and C08 assays were normal. Ultrasound of the renal tract was also normal. The patient was treated with intravenous acyclovir (5 mg/kg 8 hourly) and with oral flucloxacillin (250mg four times a day), chloramphenicol and acyclovir eye ointments and saline baths. During his stay in hospital the patient's penile and perianal
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Dhar et al. Atypical presentations of herpes simplex virus infection
443
Figure 2. Case 1: multiple erosions of the prepuce
lesions healed completely but the ocular lesions took longer to resolve. It was noticed at follow-up that he had eczematous periorbital and perianal areas and a dermatological opinion was sought. Skin tests confirmed atopy with marked reaction to house dust, horse dust mite, cat hair and sporobolycies mould. RAST and IgE levels further substantiated t~e diagnosis and consequently a topical steroid Ointment was added to his treatment regimen. Treatment with oral acyclovir was continued for 3 months until the eczematous areas had cleared. Haematuria, which had been documented initially Was further investigated with renal function tests, complement profile and intravenous urography, all of which were normal.
Case 2 A 32-year-old Caucasian married man, presented to the department with a 4-day history of feeling unwell, general malaise, pain with tightness of the left groin and tingling in the left groin. This was followed by swelling of the penis, scrotum and the left groin and the appearance of a painful vesicular eruption on the penile shaft on the day before attending the clinic. The patient had suffered 4-5 episodes of genital h~rpes every year for the last 6 years; these had been mIld and had not necessitated medical attention. Physical examination revealed a febrile and toxic patient with a temperature of 38.6°C; a vesicular eruption on the penile shaft, marked penile and scrotal oedema (Figure 3) with extensive cellulitis ~specially in the left inguinal area. Laboratory Investigations, which included a full blood count, urine and liver function tests, were normal. Herpes simplex virus type 2 was isolated from the penile shaft. No other organisms were found on culture of Swabs taken from the penis.
Figure 3. Case 2: swelling of the penis with vesicular eruption on the penile shaft
The patient was treated with oral acyclovir (200mg 5 times a day) and flucloxacillin (250mg four times a day). Recovery was protracted. The cellulitis took 4 weeks to resolve but penile oedema continued and was still present at 8 weeks. Since then the patient has been seen in the clinic with a recurrent attack. DISCUSSION
Extensive mucocutaneous HSV infection, as seen in case I, is well documented in neonates but is rare in healthy, well nourished adults". Involvement of this severity warrants scrutiny for predisposing factors such as an underlying skin disorder, (eg pemphigus, dermatitis or eczema), a hypoproteinemic state (eg malnutrition or a protein losing enteropathy) or an immunosuppressed state (eg HIV infection or cytotoxic therapy) 1. Clinically, eczema herpeticum is a disseminated HSV infection occurring in patients with preexisting dermatitis'. However, active dermatitis is not necessary for the development of these lesions as illustrated by case 1 whose present episode occurred at a time when the skin was clear. Atopies are prone to bacterial and viral infections, particularly HSV. This is partly due to the ease of infection through
Downloaded from std.sagepub.com at UNIVERSITY OF WINDSOR on December 5, 2016
444
International Journal of STD & AIDS Volume 3 NovemberlDecember 1992
the broken skin and partly because some atopies have an abnormality of their T cell function. The distribution of the lesions in this case suggests that the majority of extra genital involvement developed by autoinnocu1ation rather than viremic spread. Prompt, treatment with systemic acyclovir accelerates the healing of lesions with consequent reduction in pain. It also prevents the dissemination to viscera which may complicate extensive HSV infections. The course of recurrent genital HSV type 2 is similar to HSV type 1 infection. The majority of patients have a prodrome of pain or tingling in the affected area followed by vesicular ulceration, crusting and healing6. However, the recurrence rate of genital disease caused by the two subtypes of the virus differ. HSV type 2 has a greater propensity for recurrence in the genital area compared with HSV Type 17• Case 2 highlights the variability in presentation between patients and in the same patient with the passage of time. Genital herpes presenting as cellulitisand oedema of the severity as seen in case 2 is rare. However, HSV infection elsewhere (eg digits) may present with oedema, erythema and tenderness and in these instances it may be indistinguishable from a pyogenic bacterial infectionS, like the penile lesions in case 2. It is therefore important to consider HSV infection in the differential diagnosis of genital cellulitis to avoid unnecessary investigations and to allow early initiation of treatment, should HSV be diagnosed. The above cases thus highlight the need for an increased awareness and recognition of the diversity
of clinical manifestations of HSV infections, not only in the immunocompromised individual but also in healthy young adults.
Acknowledgment: We thankDr 0 P Arya, Consultant and Director of the Department of Genitourinary Medicine, Royal Liverpool Hospital for his help in preparing this paper. References 1 Nahmias AJ. Disseminated herpes simplex virus infections. N Engl J Med 1970;282:684-5 2 Corey L, Adams HG, Brown ZA, Holmes KK. Genital herpes simplex virus infection: clinical manifestations, course and complications. Ann Intern Med 1983;98:958-72 3 Moedy JLA, Lerman SJ, White RJ. Fatal disseminated herpes simplex virus infection in a healthy child. Am J Dis Child 1981;135:45-7
4 Mailman C], Miranda JL, Spock A. Recurrent eczema herpeticum. Arch Dermatoll964;89:815-8 5 Robinson GE, Underhill GS, Forster GE, Kennedy C, Mclean K. Treatment with acyclovir of genital herpes simplex infection complicated by eczema herpeticum. Br J Vener Dis 1984; 60:241-2 6 Guinan ME, MacCalman J, Kern ER, Overall JC[r, Spruance SL. The course of an untreated episode of recurrent genital herpes simplex infection in 27 women. N Engl J Med 1981;304:759-63
7 Mindel A, Weller IVD, Faherty A, Sutherland 5, Fiddian AP, Adler MW. Acyclovir in first attacks of genital herpes and prevention of recurrences. Genitourinary Med 1986;62:28-32 8 Corey L, Spear PG. Infections with herpes simplex viruses. N Engl
J Med
1986;314:749-57
(Accepted 2 June 1992)
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CASE REPORT
Atypical presentations of herpes simplex virus infection Jyoti Dhar MRCP, P B Carey MRCP and A B Alawattegama MRCOG University Department of Genitourinary Medicine, Royal Liverpool Hospital, Prescot Street, Liverpool L7 8XP, UK Keywords: Genital herpes, eczema herpeticum, mucocutaneous lesions, recurrent attacks, cellulitis
Herpes simplex virus (HSV) infection has been medically recognized for several centuries and affects close to 100% of individuals in certain population groups 1. The clinical presentation of genital herpes varies greatly depending partly on whether it is a primary or a recurrent infection. Irritation, pain, dysuria, urethral discharge and tender non-suppurative inguinal lymphadenopathy are the predominant local symptoms associated with vesicular or ulcerative lesions as the presenting clinical features-. We report two patients with unusual presentations recently seen in the Department of Genitourinary Medicine at the Royal Liverpool Hospital. Figure 1. Case 1: bilateral conjunctivitis, periorbital and palpebral oedema with pus exuding from cracked, ulcerated and crusted eyelids
CASE REPORTS
Case 1
AR, a 36-year-oldCaucasian, quality control engineer, in a monogamous relationship was referred to the clinic with a history of a flu-like illness followed 2 weeks later by dysuria, tenderness of the glans penis, anal discomfort and an ulcer near the left ear. In the previous 5 days he had received treatment for an infection of the left eye with amoxycillin and an eye ointment, and clotrimazole cream for local application to the glans penis, by his general practitioner. Except for a past history of herpes labialis, his health before this illness had been excellent. Physical examination revealed a febrile patient with erosions on the forehead, severe bilateral conjunctivitis, marked periorbital and palpebral oedema with pus exuding from cracked, ulcerated and crusted eyelids (Figure 1). There was evidence of healed angular cheilitis and mild glossitis. There were multiple tender erosions of the prepuce and a bleeding ulcer on the glans penis (Figure 2). The prepuce, although phimotic, was retractable. There were extensive anal and perianal vesicles and ulcers. Correspondence to: Dr J Dhar. University Department of Genitourinary Medicine, Royal Liverpool Hospital, Prescot Street, Liverpool L7 8XP, UK
There were no other mucocutaneous lesions and the systemic examination was normal. An ophthalmological opinion revealed bilateral dendritic ulcers with a few cells in the anterior chamber and secondary iritis of the left eye. These findings suggested extensive mucocutaneous HSV infection and the patient was admitted to hospital. Laboratory investigations revealed normal full blood count with an elevated erythrocyte sedimentation rate at 60 mm/1st hour. HSV type 1 was cultured from swabs taken from the eyes and the anal and perianal areas. In addition, Staphylococcus aureus was grown from the eyes and the urine showed macroscopic haematuria with some hyaline and granular casts. No pathogens were isolated from the urine and cytological assessment for malignant cells was negative. Serological tests for syphilis, hepatitis B and human immunodeficiency virus (HIV) infection were negative as were tests for autoantibodies and cytomegalovirus. Serum immunoglobulin and CD4 and C08 assays were normal. Ultrasound of the renal tract was also normal. The patient was treated with intravenous acyclovir (5 mg/kg 8 hourly) and with oral flucloxacillin (250mg four times a day), chloramphenicol and acyclovir eye ointments and saline baths. During his stay in hospital the patient's penile and perianal
Downloaded from std.sagepub.com at UNIVERSITY OF WINDSOR on December 5, 2016
Dhar et al. Atypical presentations of herpes simplex virus infection
443
Figure 2. Case 1: multiple erosions of the prepuce
lesions healed completely but the ocular lesions took longer to resolve. It was noticed at follow-up that he had eczematous periorbital and perianal areas and a dermatological opinion was sought. Skin tests confirmed atopy with marked reaction to house dust, horse dust mite, cat hair and sporobolycies mould. RAST and IgE levels further substantiated t~e diagnosis and consequently a topical steroid Ointment was added to his treatment regimen. Treatment with oral acyclovir was continued for 3 months until the eczematous areas had cleared. Haematuria, which had been documented initially Was further investigated with renal function tests, complement profile and intravenous urography, all of which were normal.
Case 2 A 32-year-old Caucasian married man, presented to the department with a 4-day history of feeling unwell, general malaise, pain with tightness of the left groin and tingling in the left groin. This was followed by swelling of the penis, scrotum and the left groin and the appearance of a painful vesicular eruption on the penile shaft on the day before attending the clinic. The patient had suffered 4-5 episodes of genital h~rpes every year for the last 6 years; these had been mIld and had not necessitated medical attention. Physical examination revealed a febrile and toxic patient with a temperature of 38.6°C; a vesicular eruption on the penile shaft, marked penile and scrotal oedema (Figure 3) with extensive cellulitis ~specially in the left inguinal area. Laboratory Investigations, which included a full blood count, urine and liver function tests, were normal. Herpes simplex virus type 2 was isolated from the penile shaft. No other organisms were found on culture of Swabs taken from the penis.
Figure 3. Case 2: swelling of the penis with vesicular eruption on the penile shaft
The patient was treated with oral acyclovir (200mg 5 times a day) and flucloxacillin (250mg four times a day). Recovery was protracted. The cellulitis took 4 weeks to resolve but penile oedema continued and was still present at 8 weeks. Since then the patient has been seen in the clinic with a recurrent attack. DISCUSSION
Extensive mucocutaneous HSV infection, as seen in case I, is well documented in neonates but is rare in healthy, well nourished adults". Involvement of this severity warrants scrutiny for predisposing factors such as an underlying skin disorder, (eg pemphigus, dermatitis or eczema), a hypoproteinemic state (eg malnutrition or a protein losing enteropathy) or an immunosuppressed state (eg HIV infection or cytotoxic therapy) 1. Clinically, eczema herpeticum is a disseminated HSV infection occurring in patients with preexisting dermatitis'. However, active dermatitis is not necessary for the development of these lesions as illustrated by case 1 whose present episode occurred at a time when the skin was clear. Atopies are prone to bacterial and viral infections, particularly HSV. This is partly due to the ease of infection through
Downloaded from std.sagepub.com at UNIVERSITY OF WINDSOR on December 5, 2016
444
International Journal of STD & AIDS Volume 3 NovemberlDecember 1992
the broken skin and partly because some atopies have an abnormality of their T cell function. The distribution of the lesions in this case suggests that the majority of extra genital involvement developed by autoinnocu1ation rather than viremic spread. Prompt, treatment with systemic acyclovir accelerates the healing of lesions with consequent reduction in pain. It also prevents the dissemination to viscera which may complicate extensive HSV infections. The course of recurrent genital HSV type 2 is similar to HSV type 1 infection. The majority of patients have a prodrome of pain or tingling in the affected area followed by vesicular ulceration, crusting and healing6. However, the recurrence rate of genital disease caused by the two subtypes of the virus differ. HSV type 2 has a greater propensity for recurrence in the genital area compared with HSV Type 17• Case 2 highlights the variability in presentation between patients and in the same patient with the passage of time. Genital herpes presenting as cellulitisand oedema of the severity as seen in case 2 is rare. However, HSV infection elsewhere (eg digits) may present with oedema, erythema and tenderness and in these instances it may be indistinguishable from a pyogenic bacterial infectionS, like the penile lesions in case 2. It is therefore important to consider HSV infection in the differential diagnosis of genital cellulitis to avoid unnecessary investigations and to allow early initiation of treatment, should HSV be diagnosed. The above cases thus highlight the need for an increased awareness and recognition of the diversity
of clinical manifestations of HSV infections, not only in the immunocompromised individual but also in healthy young adults.
Acknowledgment: We thankDr 0 P Arya, Consultant and Director of the Department of Genitourinary Medicine, Royal Liverpool Hospital for his help in preparing this paper. References 1 Nahmias AJ. Disseminated herpes simplex virus infections. N Engl J Med 1970;282:684-5 2 Corey L, Adams HG, Brown ZA, Holmes KK. Genital herpes simplex virus infection: clinical manifestations, course and complications. Ann Intern Med 1983;98:958-72 3 Moedy JLA, Lerman SJ, White RJ. Fatal disseminated herpes simplex virus infection in a healthy child. Am J Dis Child 1981;135:45-7
4 Mailman C], Miranda JL, Spock A. Recurrent eczema herpeticum. Arch Dermatoll964;89:815-8 5 Robinson GE, Underhill GS, Forster GE, Kennedy C, Mclean K. Treatment with acyclovir of genital herpes simplex infection complicated by eczema herpeticum. Br J Vener Dis 1984; 60:241-2 6 Guinan ME, MacCalman J, Kern ER, Overall JC[r, Spruance SL. The course of an untreated episode of recurrent genital herpes simplex infection in 27 women. N Engl J Med 1981;304:759-63
7 Mindel A, Weller IVD, Faherty A, Sutherland 5, Fiddian AP, Adler MW. Acyclovir in first attacks of genital herpes and prevention of recurrences. Genitourinary Med 1986;62:28-32 8 Corey L, Spear PG. Infections with herpes simplex viruses. N Engl
J Med
1986;314:749-57
(Accepted 2 June 1992)
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