Images in Clinical Urology Penoscrotal Mass: A Rare Presentation of Herpes Simplex Virus Infection Ryan C. Owen, Laurentia Nodit, Paul Hatcher, Wesley White, and Frederick Klein A 55-year-old man presents with a 10-cm condylomatous penoscrotal mass. Final pathology after surgical removal reveals a rare vegetative lesion with underlying herpes simplex virus infection. Along with neoplasia, infectious causes must remain in the differential diagnosis in the immunocompromised patient who presents with an atypical lesion. UROLOGY 84: e15ee16, 2014. 2014 Elsevier Inc.
Figure 1. Photograph of the lesion in vivo.
55-year-old man presents with a 10-cm condylomatous penoscrotal mass. He reports no prior exposure to sexually transmitted disease, and human immunodeﬁciency virus infection status is unknown as the patient refuses follow-up. Final pathology after partial penectomy and scrotectomy reveals a rare vegetative lesion, which stains positive with immunoperoxidase studies for both Herpes simplex virus (HSV) 1 and 2. This patient demonstrates an atypical presentation of HSV infection, which may pose a clinical diagnostic challenge. HSV infection is ubiquitous and typically Financial Disclosure: The authors declare that they have no relevant ﬁnancial interests. From the University of Tennessee Medical Center, Knoxville, TN Address correspondence to: Ryan C. Owen, M.D., University of Tennessee Medical Center, 1928 Alcoa Highway Suite 222-B, Knoxville, TN 37920. E-mail: [email protected]
utmck.edu Submitted: April 10, 2014, accepted (with revisions): July 7, 2014
ª 2014 Elsevier Inc. All Rights Reserved
Figure 2. Ulcerated skin section from the center of the lesion showing a large accumulation of acute and chronic inﬂammatory cells (with preponderance of plasma cells) and pseudoepitheliomatous hyperplasia, which can morphologically mimic squamous cell carcinoma. Low magniﬁcation (2) photomicrograph (hematoxylin and eosin stain).
presents as clustered vesicles, erosions, or ulcerations on an erythematous base with a recurrent or relapsing pattern. Less known, HSV infection can produce a persistent nodular exophytic growth (Fig. 1) predominantly in human immunodeﬁciency virusepositive patients,1 as well as in other immunosuppressed patients such as transplant recipients,2 common variable immunodeﬁciency,3 or lymphoproliferative disorders. Due to persistent tumor-like reaction, the exophytic condylomatous presentation of HSV infection raises diagnostic difﬁculties regarding discrimination between neoplasia and infection with concomitant vegetative herpes infection and squamous cell carcinoma described in the literature (Figs. 2-3).4 Oral or intravenous antiviral regimens are efﬁcacious for large vegetative lesions1,5,6; however, surgical excision with epidermal denervation offers the potential for eradication.5,7 http://dx.doi.org/10.1016/j.urology.2014.07.020 0090-4295/14
Figure 3. The periphery of the ulcer and junction with normal skin showing viral cytopathic changes with multinucleated giant cells displaying intranuclear eosinophilic inclusions, nuclear molding, and chromatin margination. Medium magniﬁcation (20) photomicrograph (hematoxylin and eosin stain).
Acknowledgments. The authors acknowledge Robert Page, M.D., Dermatopathology Partners PC for his assistance.
1. Sbidian E, Battistella M, Legoff J, et al. Recalcitrant pseudotumoral anogenital herpes simplex virus type 2 in HIV-infected patients: evidence for predominant B-lymphoplasmocytic inﬁltration and immunomodulators as effective therapeutic strategy. Clin Infect Dis. 2013;57:1648-1655. 2. Hanjani NM, Foster DC, Scott GA, Mercurio MG. A genital mass due to herpes simplex virus in a renal transplant recipient. J Low Genit Tract Dis. 2007;11:173-176. 3. Beasley KL, Cooley GE, Kao GF, et al. Herpes simplex vegetans: atypical genital herpes infection in a patient with common variable immunodeﬁciency. J Am Acad Dermatol. 1997;37: 860-863. 4. Strehl JD, Mehlhorn G, Koch MC, et al. HIV-associated hypertrophic herpes simplex genitalis with concomitant early invasive squamous cell carcinoma mimicking advanced genital cancer: case report and literature review. Int J Gynecol Pathol. 2012;31: 286-293. 5. Chung VQ, Parker DC, Parker SR. Surgical excision for vegetative herpes simplex virus infection. Dermatol Surg. 2007;33:13741379. 6. Di Lucca-Christment J, Jacobelli S, Gressier L, et al. Anogenital pseudotumoral herpes and HIV infection: a new challenge for diagnosis and treatment. AIDS. 2012;26:523-526. 7. Shelley WB. Surgical treatment for recurrent herpes simplex. Lancet. 1978;2:1021-1022.
UROLOGY 84 (5), 2014