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Int J STD AIDS OnlineFirst, published on January 22, 2015 as doi:10.1177/0956462415568983
Case report International Journal of STD & AIDS 0(0) 1–3 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462415568983 std.sagepub.com
Non-healing genital herpes mimicking donovanosis in an immunocompetent man Vishal Gupta1, Prakash Khute1, Anjali Patel2 and Somesh Gupta1
Summary Although atypical presentations of herpetic infection in immunocompetent individuals are common, they very rarely have the extensive, chronic and verrucous appearances seen in the immunocompromised host. We report a case of genital herpes manifesting as painless chronic non-healing genital ulcers with exuberant granulation tissue in an immunocompetent man. Owing to this morphology, the ulcers were initially mistaken for donovanosis. To the best of our knowledge, such a presentation of genital herpes in an immunocompetent individual has not been described previously.
Keywords Genital herpes, atypical manifestations, immunocompetent Date received: 21 October 2014; accepted: 1 January 2015
Introduction The clinical manifestations of genital herpes are varied and heterogenous. Though it is one of the most prevalent of sexually transmitted diseases, a large proportion of patients with symptomatic genital herpes remain undiagnosed, mostly due to atypical manifestations.1,2 Atypical presentations of genital herpes are increasingly being reported, even in immunocompetent patients posing a diagnostic challenge for the clinician.
Case description A 27-year-old man presented with painless genital ulcers present for three months which had initially started as multiple erythematous papules. They comprised of two lesions, one on the penile shaft measuring 2 2 cm and another on the glans penis measuring 6 8 cm. Both the ulcers had similar morphology, having well-defined margins and red exuberant granulation tissue (Figure 1(a)). The ulcers were non-tender and minimally indurated. There was no palpable or tender regional lymphadenopathy. There had been no response to multiple courses of antibiotics including cefixime, doxycycline and injectable benzathine penicillin. Over the previous three years, there had been multiple high-risk sexual exposures involving female commercial sex workers. He had an
established history of recurrent genital herpes. He had no systemic symptoms. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was non-reactive on two previous occasions. Routine investigations including full blood count, erythrocyte sedimentation rate (ESR) and peripheral blood smear; serum biochemistry and fasting blood sugar levels were normal. With the clinical possibility of donovanosis, a tissue smear was made which showed many multinucleated giant cells (MNGs) but no Donovan bodies (Figure 2). Gram stain of the ulcer exudates did not show any organism. Ulcer biopsies did not show any specific changes. Culture of the ulcer biopsy specimens for bacteria and herpes simplex virus (HSV) was negative. However, polymerase chain reaction (PCR) for HSV-2 DNA from ulcer specimens was positive. Type-specific IgG serology showed raised titres for both HSV-1 and HSV-2. Venereal Disease Research Laboratory (VDRL) test and ELISA for HIV-1 and 1 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India 2 University of Bristol, Bristol, UK
Corresponding author: Somesh Gupta, Room 4066, Teaching Block, Fourth Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India. Email: [email protected]
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2
International Journal of STD & AIDS 0(0)
Figure 1. (a) Large ulcer measuring about 6 8 cm on the glans penis extending to the prepuce, with exuberant bright red granulation tissue and a smaller ulcer on the adjacent penile shaft; (b) treatment response at two weeks with oral acyclovir.
HIV-2 were non-reactive. CD4 T-lymphocyte count was normal (739/ml). Based on the above findings, the patient was given a trial of oral acyclovir 400 mg three times daily. Within a few days, the ulcers had diminished in size by 50% and almost completely re-epithelialised at two weeks (Figure 1(b)).
Discussion Though the classical presentation of genital herpes, grouped papulovesicles and serpiginous superficial ulcers is easily recognised by clinicians, the majority of symptomatic patients (60%) remain either undiagnosed or misdiagnosed.3 Lautenschlager and Eichmann1 reported atypical manifestations of genital herpes, either morphologically or site-related, in 53% of 162 immunocompetent patients. The most common morphologically atypical form was a solitary deep and
tender ulcer. Others were abrasion-like erosion, crust, fissure, oedema or erythema. Presentation as cervicitis, hemorrhagic cystitis, recurrent urethritis and lower back pain has also been described in immunocompetent patients.2 More unusual manifestations of genital herpes such as large necrotic and chronic ulcers are well documented in immunosuppressed patients.4,5 Hypertrophic, verrucous, vegetative and tumour-like morphologies have also been described in such settings.6–8 Similar presentations have rarely been described in the immunocompetent. Recently, BaeHarboe and Khachemoune9 reported a case of verrucous herpetic infection of the inguino-scrotal region in a 60-year-old immunocompetent man. The complete absence of symptoms and loco-regional lymphadenopathy, and persistence of ulcers beyond few days or a week, as in our case, is unusual in
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Gupta et al.
3 Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References
Figure 2. Tzanck smear showing multinucleated giant cells (Giemsa; 100 ).
recurrent genital herpes in an immunocompetent host. Blood investigations within normal limits, negative HIV serology, normal CD4 count and well-preserved general health suggested no immunosuppression in our patient. Exuberant red granulation tissue at the ulcer floor raised a strong suspicion of donovanosis. However, MNGs on tissue smear, and both a positive PCR and serology for HSV-2 coupled with the rapid response to oral acyclovir suggest a diagnosis of genital herpes. To the best of our knowledge, such a presentation involving chronic ulceration has not been previously described in an immunocompetent individual. Declaration of conflicting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
1. Lautenschlager S and Eichmann A. The heterogeneous clinical spectrum of genital herpes. Dermatol Basel Switz 2001; 202: 211–219. 2. Uusku¨la A and Raukas E. Atypical genital herpes: report of five cases. Scand J Infect Dis 2004; 36: 37–39. 3. Benedetti J, Corey L and Ashley R. Recurrence rates in genital herpes after symptomatic first-episode infection. Ann Intern Med 1994; 121: 847–854. 4. Horner PJ and Harris JR. A herpes simplex skin ulcer in a patient with AIDS–an unusual presentation. Int J STD AIDS 1990; 1: 288–289. 5. Shim TN, Minhas S, Muneer A, et al. Atypical presentation of genital herpes simplex (HSV-2) in two patients with chronic lymphocytic leukemia. Acta Derm Venereol 2014; 94: 246–247. 6. Carrasco DA, Trizna Z, Colome-Grimmer M, et al. Verrucous herpes of the scrotum in a human immunodeficiency virus-positive man: case report and review of the literature. J Eur Acad Dermatol Venereol 2002; 16: 511–515. 7. Ranu H, Lee J, Chio M, et al. Tumour-like presentations of anogenital herpes simplex in HIV-positive patients. Int J STD AIDS 2011; 22: 181–186. 8. Samaratunga H, Weedon D, Musgrave N, et al. Atypical presentation of herpes simplex (chronic hypertrophic herpes) in a patient with HIV infection. Pathology (Phila) 2001; 33: 532–535. 9. Bae-Harboe YSC and 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.
(STD)
[1–3] [PREPRINTER stage]
Int J STD AIDS OnlineFirst, published on January 22, 2015 as doi:10.1177/0956462415568983
Case report International Journal of STD & AIDS 0(0) 1–3 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462415568983 std.sagepub.com
Non-healing genital herpes mimicking donovanosis in an immunocompetent man Vishal Gupta1, Prakash Khute1, Anjali Patel2 and Somesh Gupta1
Summary Although atypical presentations of herpetic infection in immunocompetent individuals are common, they very rarely have the extensive, chronic and verrucous appearances seen in the immunocompromised host. We report a case of genital herpes manifesting as painless chronic non-healing genital ulcers with exuberant granulation tissue in an immunocompetent man. Owing to this morphology, the ulcers were initially mistaken for donovanosis. To the best of our knowledge, such a presentation of genital herpes in an immunocompetent individual has not been described previously.
Keywords Genital herpes, atypical manifestations, immunocompetent Date received: 21 October 2014; accepted: 1 January 2015
Introduction The clinical manifestations of genital herpes are varied and heterogenous. Though it is one of the most prevalent of sexually transmitted diseases, a large proportion of patients with symptomatic genital herpes remain undiagnosed, mostly due to atypical manifestations.1,2 Atypical presentations of genital herpes are increasingly being reported, even in immunocompetent patients posing a diagnostic challenge for the clinician.
Case description A 27-year-old man presented with painless genital ulcers present for three months which had initially started as multiple erythematous papules. They comprised of two lesions, one on the penile shaft measuring 2 2 cm and another on the glans penis measuring 6 8 cm. Both the ulcers had similar morphology, having well-defined margins and red exuberant granulation tissue (Figure 1(a)). The ulcers were non-tender and minimally indurated. There was no palpable or tender regional lymphadenopathy. There had been no response to multiple courses of antibiotics including cefixime, doxycycline and injectable benzathine penicillin. Over the previous three years, there had been multiple high-risk sexual exposures involving female commercial sex workers. He had an
established history of recurrent genital herpes. He had no systemic symptoms. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was non-reactive on two previous occasions. Routine investigations including full blood count, erythrocyte sedimentation rate (ESR) and peripheral blood smear; serum biochemistry and fasting blood sugar levels were normal. With the clinical possibility of donovanosis, a tissue smear was made which showed many multinucleated giant cells (MNGs) but no Donovan bodies (Figure 2). Gram stain of the ulcer exudates did not show any organism. Ulcer biopsies did not show any specific changes. Culture of the ulcer biopsy specimens for bacteria and herpes simplex virus (HSV) was negative. However, polymerase chain reaction (PCR) for HSV-2 DNA from ulcer specimens was positive. Type-specific IgG serology showed raised titres for both HSV-1 and HSV-2. Venereal Disease Research Laboratory (VDRL) test and ELISA for HIV-1 and 1 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India 2 University of Bristol, Bristol, UK
Corresponding author: Somesh Gupta, Room 4066, Teaching Block, Fourth Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India. Email: [email protected]
XML Template (2015) [17.1.2015–1:07pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/STDJ/Vol00000/150002/APPFile/SG-STDJ150002.3d
(STD)
[1–3] [PREPRINTER stage]
2
International Journal of STD & AIDS 0(0)
Figure 1. (a) Large ulcer measuring about 6 8 cm on the glans penis extending to the prepuce, with exuberant bright red granulation tissue and a smaller ulcer on the adjacent penile shaft; (b) treatment response at two weeks with oral acyclovir.
HIV-2 were non-reactive. CD4 T-lymphocyte count was normal (739/ml). Based on the above findings, the patient was given a trial of oral acyclovir 400 mg three times daily. Within a few days, the ulcers had diminished in size by 50% and almost completely re-epithelialised at two weeks (Figure 1(b)).
Discussion Though the classical presentation of genital herpes, grouped papulovesicles and serpiginous superficial ulcers is easily recognised by clinicians, the majority of symptomatic patients (60%) remain either undiagnosed or misdiagnosed.3 Lautenschlager and Eichmann1 reported atypical manifestations of genital herpes, either morphologically or site-related, in 53% of 162 immunocompetent patients. The most common morphologically atypical form was a solitary deep and
tender ulcer. Others were abrasion-like erosion, crust, fissure, oedema or erythema. Presentation as cervicitis, hemorrhagic cystitis, recurrent urethritis and lower back pain has also been described in immunocompetent patients.2 More unusual manifestations of genital herpes such as large necrotic and chronic ulcers are well documented in immunosuppressed patients.4,5 Hypertrophic, verrucous, vegetative and tumour-like morphologies have also been described in such settings.6–8 Similar presentations have rarely been described in the immunocompetent. Recently, BaeHarboe and Khachemoune9 reported a case of verrucous herpetic infection of the inguino-scrotal region in a 60-year-old immunocompetent man. The complete absence of symptoms and loco-regional lymphadenopathy, and persistence of ulcers beyond few days or a week, as in our case, is unusual in
XML Template (2015) [17.1.2015–1:07pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/STDJ/Vol00000/150002/APPFile/SG-STDJ150002.3d
(STD)
[1–3] [PREPRINTER stage]
Gupta et al.
3 Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References
Figure 2. Tzanck smear showing multinucleated giant cells (Giemsa; 100 ).
recurrent genital herpes in an immunocompetent host. Blood investigations within normal limits, negative HIV serology, normal CD4 count and well-preserved general health suggested no immunosuppression in our patient. Exuberant red granulation tissue at the ulcer floor raised a strong suspicion of donovanosis. However, MNGs on tissue smear, and both a positive PCR and serology for HSV-2 coupled with the rapid response to oral acyclovir suggest a diagnosis of genital herpes. To the best of our knowledge, such a presentation involving chronic ulceration has not been previously described in an immunocompetent individual. Declaration of conflicting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
1. Lautenschlager S and Eichmann A. The heterogeneous clinical spectrum of genital herpes. Dermatol Basel Switz 2001; 202: 211–219. 2. Uusku¨la A and Raukas E. Atypical genital herpes: report of five cases. Scand J Infect Dis 2004; 36: 37–39. 3. Benedetti J, Corey L and Ashley R. Recurrence rates in genital herpes after symptomatic first-episode infection. Ann Intern Med 1994; 121: 847–854. 4. Horner PJ and Harris JR. A herpes simplex skin ulcer in a patient with AIDS–an unusual presentation. Int J STD AIDS 1990; 1: 288–289. 5. Shim TN, Minhas S, Muneer A, et al. Atypical presentation of genital herpes simplex (HSV-2) in two patients with chronic lymphocytic leukemia. Acta Derm Venereol 2014; 94: 246–247. 6. Carrasco DA, Trizna Z, Colome-Grimmer M, et al. Verrucous herpes of the scrotum in a human immunodeficiency virus-positive man: case report and review of the literature. J Eur Acad Dermatol Venereol 2002; 16: 511–515. 7. Ranu H, Lee J, Chio M, et al. Tumour-like presentations of anogenital herpes simplex in HIV-positive patients. Int J STD AIDS 2011; 22: 181–186. 8. Samaratunga H, Weedon D, Musgrave N, et al. Atypical presentation of herpes simplex (chronic hypertrophic herpes) in a patient with HIV infection. Pathology (Phila) 2001; 33: 532–535. 9. Bae-Harboe YSC and 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.
