#idgrandrounds
32F w/ HIV, stared ART 9 mos ago (CD4 90, now 170), p/w 4 wks, slightly tender, hypertrophic vulvar lesion (representative pic 👇). Lives in US. Biopsy: no malignancy, culture (-).
Diagnosis? Differentials? @TxID_Edu @BradCutrellMD @DocWoc71 @Cortes_Penfield
@TxID_Edu @BradCutrellMD @DocWoc71 @Cortes_Penfield 1/9
PCR, histopath c/w HSV. Failed to respond to valacyclovir, foscarnet (viral culture w/ no resistance). Cured w/ surgical resection + valacyclovir.
CASE RESOLUTION: 𝐇𝐞𝐫𝐩𝐞𝐬 𝐯𝐞𝐠𝐞𝐭𝐚𝐧𝐬 (hypertrophic HSV)
Picture in MCQ from: researchgate.net/publication/23…
2/9
Typical illness script for HSV esp in immunocompetent patients:
✔️ painful ulcers, vesicles/group of vesicles that ulcerate
Among immunocompromised patients, HSV can also manifest atypically. 𝐇𝐞𝐫𝐩𝐞𝐬 𝐯𝐞𝐠𝐞𝐭𝐚𝐧𝐬 is one of the atypical HSV manifestations.
3/9
𝐇𝐞𝐫𝐩𝐞𝐬 𝐯𝐞𝐠𝐞𝐭𝐚𝐧𝐬
▪️ exophytic, verrucous, tumor-like presentation of HSV
▪️ seen in immunocompromised patients, in particular people with HIV
Occurrence among people with HIV is independent of CD4 ncbi.nlm.nih.gov/pubmed/25660091 and no strong evidence w/ IRIS.
4/9
Thought to be a/w HIV-associated immune-dysregulation but exact pathogenesis is unclear:
▪️ HIV-infected dendritic cells in the epidermis overproduce anti-apoptotic TNF & IL-6
▪️ leads to keratinocyte proliferation and hyperkeratosis
ncbi.nlm.nih.gov/pubmed/17205432
5/9
Pathology: epithelial hyperplasia, ulceration, scattered multinucleated cells typical of HSV (see 👇)
Pic from:
escholarship.org/uc/item/1zt833…
6/9
Tends to be very difficult to treat. May not respond to courses of antiviral. Not unusual to receive cidofovir/foscarnet for c/f resistant HSV. Approaches that have been reported to be successful:
▪️ Imiquimod
▪️ Intralesional cidofovir
▪️ Thalidomide
▪️ Surgery + antiviral
7/9
Differential diagnoses for genital mass:
▪️ Malignancy
▪️ Buschke-Lowenstein tumor (giant condyloma acuminatum). Thought to be from HPV 6, 11
Pic from:
oghreports.phcog.interactivedns.com/article/157
8/9
Other differentials:
▪️ Condyloma lata
▪️ Deep fungal or protozoal infections
▪️ Pemphigus vegetans 👇 (autoimmune)
Pic from:
researchgate.net/publication/33…
9/9
Important to have an illness script for atypical HSV presentation.
Awesome DDx @TxID_Edu @Ornate_Brute @atrummedic! @CathalOBroin suspected it!
Expert consultation:
@DrStevenTChen Are there any other atypical HSV presentations clinicians need to know about?
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